ArticlePDF Available

Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: A retrospective study comparing functional and radiological outcomes

Authors:

Abstract and Figures

Aims: The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations. Patients and methods: A total of 108 patients were treated for a Lisfranc fracture dislocation over a period of nine years. Of these, 38 underwent transarticular screw fixation, 45 dorsal bridge plating, and 25 a combination technique. Injuries were assessed preoperatively according to the Myerson classification system. The outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, the validated Manchester Oxford Foot Questionnaire (MOXFQ) functional tool, and the radiological Wilppula classification of anatomical reduction. Results: Significantly better functional outcomes were seen in the bridge plate group. These patients had a mean AOFAS score of 82.5 points, compared with 71.0 for the screw group and 63.3 for the combination group (p < 0.001). Similarly, the mean Manchester Oxford Foot Questionnaire score was 25.6 points in the bridge plate group, 38.1 in the screw group, and 45.5 in the combination group (p < 0.001). Functional outcome was dependent on the quality of reduction (p < 0.001). A trend was noted which indicated that plate fixation is associated with a better anatomical reduction (p = 0.06). Myerson types A and C2 significantly predicted a poorer functional outcome, suggesting that total incongruity in either a homolateral or divergent pattern leads to worse outcomes. The greater the number of columns fixed the worse the outcome (p < 0.001). Conclusion: Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique. Cite this article: Bone Joint J 2018;100-B:468-74.
Content may be subject to copyright.
468 THE BONE & JOINT JOURNAL
FOOT AND ANKLE
Dorsal bridge plating or transarticular screws
for Lisfranc fracture dislocations
A RETROSPECTIVE STUDY COMPARING FUNCTIONAL AND
RADIOLOGICAL OUTCOMES
N. Kirzner,
P. Zotov,
D. Goldbloom,
H. Curry,
H. Bedi
From Alfred
Hospital, Melbourne,
Australia
N. Kirzner, MBBS, BSc,
MRadTher, Orthopaedic
Registrar
P. Zotov, MBBS,
Orthopaedic Resident
D.Goldbloom, MBBS,
FRACS(Ortho),
Orthopaedic Consultant
H.Curry, MBBS,
FRACS (Ortho),
Orthopaedic Consultant
H. Bedi, MBBS, FRACS
(Ortho), MPH,
Orthopaedic Consultant
Alfred Hospital, 55 Commercial
Road, Melbourne, Victoria
3004, OrthoSports Victoria,
Level 5, 89 Bridge Rd ,
Richmond, Victoria 312,
Australia.
Correspondence should be sent
to N. Kirzner; email:
Nathan.kirzner@gmail.com
©2018 Kirzner et al
doi:10.1302/0301-620X.100B4.
BJJ-2017-0899.R2 $2.00
Bone Joint J
2018;100-B:468–74.
Aims
The aim of this retrospective study was to compare the functional and radiological
outcomes of bridge plating, screw fixation, and a combination of both methods for the
treatment of Lisfranc fracture dislocations.
Patients and Methods
A total of 108 patients were treated for a Lisfranc fracture dislocation over a period of nine
years. Of these, 38 underwent transarticular screw fixation, 45 dorsal bridge plating, and 25
a combination technique. Injuries were assessed preoperatively according to the Myerson
classification system. The outcome measures included the American Orthopaedic Foot and
Ankle Society (AOFAS) score, the validated Manchester Oxford Foot Questionnaire (MOXFQ)
functional tool, and the radiological Wilppula classification of anatomical reduction.
Results
Significantly better functional outcomes were seen in the bridge plate group. These patients
had a mean AOFAS score of 82.5 points, compared with 71.0 for the screw group and 63.3
for the combination group (p < 0.001). Similarly, the mean Manchester Oxford Foot
Questionnaire score was 25.6 points in the bridge plate group, 38.1 in the screw group, and
45.5 in the combination group (p < 0.001).
Functional outcome was dependent on the quality of reduction (p < 0.001). A trend was
noted which indicated that plate fixation is associated with a better anatomical reduction
(p = 0.06). Myerson types A and C2 significantly predicted a poorer functional outcome,
suggesting that total incongruity in either a homolateral or divergent pattern leads to worse
outcomes. The greater the number of columns fixed the worse the outcome (p < 0.001).
Conclusion
Patients treated with dorsal bridge plating have better functional and radiological outcomes
than those treated with transarticular screws or a combination technique.
Cite this article: Bone Joint J 2018;100-B:468–74.
Lisfranc fracture dislocations consist of
injuries to the bases of the five metatarsals
(MTs), their articulations with the four distal
tarsal bones, and disruption of the Lisfranc
ligamentous complex.1 They have a reported
incidence of one per 50 000 people each year,
and account for approximately 0.2% of all
fractures.2-5 One-third are the result of a low
energy twisting injury: the remainder are
typically the result of high-velocity trauma.6
Most are unstable or displaced and require
operative intervention.7 The goals of treatment
are to achieve a painless, plantigrade, stable
foot, with return to its premorbid function.4
Evidence suggests that maintenance of
anatomical alignment is a critical factor in
achieving a good functional outcome.7-10
However, despite the routine usage of surgical
fixation post-traumatic arthritis remains a
problem in up to 94% of cases.9,11,12
Traditionally, the benchmark of treatment
has been open reduction and internal fixation
(ORIF) with transarticular screws.13 Recently,
however, there has been a trend towards the
use of dorsal bridge plating in an attempt to
avoid additional damage to the joint from
screw penetration.10,14-16 Cadaveric studies
have shown that the use of transarticular
screws leads to additional damage to the
articular surface of between 2% and 6%.17,18
The use of plates was first described in 2003 as
a temporary bridge over the medial column of
DORSAL BRIDGE PLATING OR TRANSARTICULAR SCREWS FOR LISFRANC FRACTURE DISLOCATIONS 469
VOL. 100-B, No. 4, APRIL 2018
the tarsometatarsal joint (TMTJ).8 Recent cadaveric studies
have shown that plates provide stiffer fixation and result in
less displacement than screws on static and cyclic
loading,19,20 while avoiding additional damage to the
TMTJ.17
Currently, there are only a few studies of small sample
size which have compared the functional20,21 or
radiological22 outcomes of transarticular screws and dorsal
bridge plating for Lisfranc injuries. The primary purpose of
this retrospective cohort study was to compare the
functional and radiological outcomes of dorsal bridge
plating for a Lisfranc fracture dislocation with
transarticular screw fixation and a combination of both
techniques.
Patients and Methods
Using our hospital’s electronic database, orthopaedic unit
audit and the search terms ‘open reduction of fracture of
the TMTJ with internal fixation’ and the Medicare benefits
schedule (MBS) codes 47624, 47648, and 47621, we
identified all patients who had sustained a Lisfranc fracture
dislocation between 1 January 2005 and 30 June 2016. The
Alfred hospital’s human research ethics committee
provided ethical approval for the study.
In the 11-year study period, a total of 158 patients
presented with a Lisfranc injury. Patients were excluded
from the study if they had been managed conservatively
(n = 22), lost to follow-up, refused involvement, or had
undergone primary arthrodesis (n = 25). A further two
patients had died before the time of contact: one patient
with a Charcot foot23 was also excluded leaving 108
patients in the study (Table I). There were 78 men and 30
women with a mean age of 39.40 years (19 to 81). The
injury was in the right foot in 57 patients and the left in 51.
Bridge plating was used in 45 patients (42%), transarticular
screws in 38 patients (35%), and a combination of the two
in 25 patients (23%). There were a high proportion (65%)
of high-energy injuries, smokers (24%) and diabetics (9%).
This is likely due to the level 1 trauma and tertiary referral
nature of our hospital. The demographics of the three
groups were comparable, although the bridge plate group
had a greater percentage of smokers (31%) and open
fractures (18%), and a shorter mean follow-up. The
mechanism of injury, Myerson classification24 and the
mean number of columns fixed are given in Table I. The
mean follow-up period was 34 months.
Patient data, including gender, age, smoking habits,
diabetic status, trauma mechanism, open or closed injury,
operation type, postoperative complications, implant
removal, and follow-up data were retrieved. Postoperative
complications were assessed from follow-up outpatient
clinic notes and divided into: soft-tissue complications,
including superficial and deep wound infections and
neurovascular injury; malfixation and loss of fixation,
including broken screws; severe pain; and nonunion or
malunion. The institution’s human research ethics
committee provided ethical approval for the study.
The preoperative radiographs and CT scans were
reviewed to identify associated injuries: the type of injury
was categorized using the Myerson classification.24 The
postoperative imaging studies and operating notes were
used to divide patients into three groups according to the
type of surgery performed: 1) fixation of the TMTJ with
transarticular screws; 2) dorsal plate fixation of the TMTJ;
or 3) fixation of the TMTJ with a combination of dorsal
plates and transarticular screws. In group 3, the use of
Table I.Patient and trauma characteristics and functional outcome
Characteristic Bridge plate (n = 45) Transarticular screws (n = 38) Combination (n = 25)
Male gender, n (%) 31 (69) 31 (82)16 (64)
Median age at injury, yrs (range) 35 (19 to 77) 39 (21 to 81) 35 (23 to 67)
Smoker, n (%) 14 (31)6 (16)6 (24)
Diabetes, n (%) 3 (7)5 (13)2 (8)
Trauma mechanism, n
Motor vehicle accident 21 18 15
Fall 7 11 4
Inversion injury 11 6 5
Crush injury631
Open fracture, n (%) 8 (18)4 (11)3 (12)
Removal of metal, n (%) 33 (73) 36 (95)20 (80)
Columns fixed, n 1.9 2.1 2.5
Median follow-up, months (range) 23 (6 to 96) 38 (12 to 131) 40 (7 to 110)
Myerson classification, n
A 6 10 10
B1 19 8 2
B2 13 12 6
C1554
C2233
Mean AOFAS score (range) 82 (60 to 100) 71 (5 to 95) 63 (18 to 100)
MOXFQ score (range) 26 (16 to 49) 38 (17 to 77) 46 (16 to 77)
Overall satisfaction, n (%) 32 (71) 21 (55)8 (32)
AOFAS, American Orthopaedic Foot and Ankle Society midfoot score; MOXFQ, Manchester Oxford Foot Questionnaire
470 N. KIRZNER, P. ZOTOV, D. GOLDBLOOM, H. CURRY, H. BEDI
Follow us @BoneJointJ THE BONE & JOINT JOURNAL
plates and screws did not necessarily occur across the same
TMTJ (Fig. 1). In terms of choice of implants, there was a
move away from screws to plate fixation in 2007. Initially,
plates were used in combination with screws for more
severe injuries, in an attempt to provide adequate fixation.
As evidence emerged that plate fixation was performing
well, it started to be used on its own. Plates also became
more popular as newer designs such as locking plates with
reduced profiles became available. Ultimately, the choice of
fixation selected was surgeon dependent. Other than the
first two, all patients were fixed with locking plates. Of the
68 locking plates, 58 were manufactured by Synthes
(DePuy Synthes; 2.7-mm foot plating system, Paoli,
Pennsylvania) and ten were manufactured by Medartis;
2.8-mm APTUS trilock plating system (Basel, Switzerland).
In total, 70 patients underwent plate fixation.
As the Lisfranc interval was only fixed with a
transarticular screw in all cases, it was excluded when
determining to which of the three groups the fixation
belonged. Similarly, screws which transfixed any
intercuneiform dislocation were also ignored when
classifying the type of fixation. Group 3 therefore only
included plate and/or screw fixation across multiple
TMTJs. Surgery was performed by three surgeons (HB,
HC, and DG), who were all members of a single surgical
unit. The two junior surgeons (HC and DG) were previous
fellows of HB and used similar techniques. All procedures
were open to ensure good reduction. The intention of the
surgeon was to achieve joint reduction and fixation rather
than fusion.
The columns fixed were grouped into three, as
previously described:
25
the rigid medial column (1st
metatarsal and 1st cuneiform), a middle column (2nd and
3rd metatarsals and their respective cuneiforms), and the
relatively mobile lateral column (consisting of 4th and 5th
metatarsals articulating with the cuboid).
1,26
After
fixation of the medial two columns, the lateral column
was assessed fluoroscopically and, if unstable or
incompletely reduced, Kirschner wire (K-wire) fixation
was undertaken. The
K-wires were removed after six to
eight weeks. Postoperative rehabilitation was the same in
all groups and consisted of six weeks non-weight-bearing,
followed by protected weight-bearing in a controlled ankle
motion (CAM) boot until three months had elapsed. Arch
supports were used between three and six months. Implant
removal, when carried out, occurred at a minimum of six
months postoperatively.
Functional outcomes were measured by the American
Orthopaedic Foot and Ankle Society (AOFAS) midfoot
score27 and the validated Manchester Oxford Foot
Questionnaire (MOXFQ).28 The latter is scored inversely, a
lower score indicating a better outcome. Finally, patient
responses were recorded for overall satisfaction as either
satisfied or not satisfied.
The anatomical reduction (alignment, length, and
Lisfranc interval diastasis) was assessed on postoperative
images using the Wilppula classification of good, fair, or
poor. Using this system a good anatomical reduction is
described as a good overall shape of the foot, with a
diastasis between the 1st and 2nd metatarsal bases < 5 mm
and the presence of slight or no arthrosis. A fair anatomical
reduction is described as a 1st and 2nd metatarsal base
diastasis of 6 mm to 9 mm and slight or moderate arthrosis.
Finally, a poor anatomical reduction is defined as marked
deformity (e.g. cavus, abduction or adduction, shortening,
or 1st metatarsal dislocation), with a diastasis between the
1st and 2nd metatarsal bases of > 10 mm and moderate to
severe arthrosis.29
Differences in proportions between groups were
compared using the chi-squared test for equal proportions
or Fisher’s exact test where numbers were small.
Comparisons of functional outcomes between groups were
made using one-way analysis of variance or the Kruskal–
Wallis test where appropriate.
Results
Primary functional outcomes are presented in Table I.
Statistically, dorsal bridge plate fixation was significantly
better than both screw fixation and a combination
technique. The mean AOFAS score was 82.5 (59 to 100) in
the bridge plate group, 71.1 (5 to 95) in the screw group,
and 63.3 (18 to 100) in the combination group (p < 0.001).
Overall, 24 patients had an excellent outcome (score 90);
36 a good outcome (90 > score 75); 36 a fair outcome
(75 > score 50); and 12 a poor outcome (score < 49). This
was reflected by the mean MOXFQ scores which were 25.6
(16 to 49) in the bridge plate group, 38.1 (17 to 77) in the
screw group, and 45.5 (16 to 77) in the combination group
(p < 0.001).
Anatomical reduction was determined using Wilppula’s
classification system.29 Good or anatomical reduction was
achieved in 37 of 45 (82.2%) cases of bridge plate fixation,
26 of 38 (68.4%) of transarticular screw fixation, and 14 of
25 (56.0%) cases in which a combination of the two
fixation techniques was used. The type of surgery and grade
Fig. 1
Radiograph of a foot from the transarticular screw group, a foot
from the bridge plate group, and a foot from the combination
group.
DORSAL BRIDGE PLATING OR TRANSARTICULAR SCREWS FOR LISFRANC FRACTURE DISLOCATIONS 471
VOL. 100-B, No. 4, APRIL 2018
of anatomical reduction are shown in Table II. There was a
loss of quality of reduction in all three groups over time.
However, the rate of loss of a good quality reduction was
twice as high in the screw and combination groups as in the
plate group (24% versus 11%). Furthermore, there was a
trend towards a better anatomical reduction at final follow-up
than in the screw and combination groups. However, this did
not quite reach statistical significance (chi-squared
= 5.64,
p=0.06).
Subgroup analyses directly compared functional
outcome scores with the Myerson classification, the
number of columns fixed, and quality of anatomical
reduction (Table III). Myerson types A and C2 had worse
functional outcomes than types B1, B2, and C1 (p < 0.001)
on both the AOFAS (65 and 53, respectively) and MOXFQ
(43 and 48, respectively) scores. An association was also
found between the radiological and functional outcome
measures. A poor functional outcome was seen in patients
with a poor Wilppula classification (AOFAS 30, MOXFQ
66; p < 0.001). A worse functional outcome was also
associated with an increased number of columns fixed.
Three-column fixation had a mean AOFAS score of 64 (5 to
100) and MOXFQ of 42 (16 to 77), compared with an
AOFAS of 77 (36 to 100) and MOXFQ of 33 (16 to 65)
with two-column fixation, and an AOFAS of 84 (52 to 100)
and MOXFQ of 24 (16 to 38) with one-column fixation
(p < 0.001).
To ensure that the improved outcomes seen in the bridge
plating group were not the result of a learning curve
phenomenon, the data set was chronologically ordered and
divided into roughly equal halves. There were 53 patients in
the earlier time period, between January 2005 and May
Table II. Immediate and latest Wilppula anatomical reduction stratified by type of surgery
Surgical technique Wilppula anatomic reduction p-value*
Good Fair Poor
Screws, immediate vs latest POR, n (%) 35 (92) vs 26 (68)3 (8) vs 9 (24)0 (0) vs 3 (8)0.003
Plates, immediate vs latest POR, n (%) 42 (93) vs 37 (82)3 (7) vs 7 (16)0 (0) vs 1 (2)0.03
Combo, immediate vs latest POR, n (%) 20 (80) vs 14 (56)5 (20) vs 7 (28)0 (0) vs 4 (16)0.014
*chi-squared
POR, Postoperative radiograph
Table III. Myerson classification, Wilppula anatomical reduction, and columns fixed, stratified by
functional outcome measures
Variables AOFAS foot score MOXFQ foot score
Myerson classification
A6543
B1 81 28
B2 77 33
C1 81 30
C2 53 48
Wilppula anatomical reduction
Good 80 29
Fair 67 41
Poor 30 66
No. of columns fixed
18424
27733
36442
AOFAS, American Orthopaedic Foot and Ankle Society midfoot score; MOXFQ, Manchester Oxford
Foot Questionnaire
Table IV. Wilppula28 anatomical reduction stratified by type of surgery across two time periods
Surgical type Wilppula anatomic reduction, 2005 to 2012 Wilppula anatomic reduction, 2013 to 2016 p-value*
Good Fair Poor Good Fair Poor
Screw, n (%) 20 (69)7 (24)2 (7) 6 (67)2 (22)1 (11)1.00
Plate, n (%) 8 (80)2 (20)0 (0) 29 (83)5 (14)1 (3)1.00
Combination, n (%) 9 (64)3 (22)2 (14)5 (45)4 (37)2 (18)0.44
Total 37 (70) 12 (23)4 (7) 40 (73)11 (20)4 (7)0.74
*chi-squared
472 N. KIRZNER, P. ZOTOV, D. GOLDBLOOM, H. CURRY, H. BEDI
Follow us @BoneJointJ THE BONE & JOINT JOURNAL
2012, and 55 in the later period between June 2012 and
June 2016. There was no observed improvement in the
quality of reduction between the two time periods using
any method of fixation, suggesting that a learning curve
was not a confounding factor (Table IV).
The complications for each type of operation are listed in
Table V. In the screw fixation group, there was one patient
with osteomyelitis who required washout and debridement
of the wound, a prolonged course of intravenous antibiotics
and removal of the implants. Two other patients had
superficial wound infections which were treated solely with
antibiotics. In the dorsal plate fixation group, three patients
had ongoing deep peroneal nerve (DPN) paraesthesia and
four had broken screws. In the combination group, three
patients had broken screws. Severe postoperative pain was
reported in nine of 25 patients in this group: two patients
required an arthrodesis.
Discussion
Currently, there is no consensus about best practice and few
s
tudies
20,21
which compare the radiological and functional
outcomes after dorsal bridge plating and transarticular
screw fixation. While debate continues about the best
method of fixation, there is, however, a consensus that the
anatomical, stable reduction of a Lisfranc injury is a
prerequisite for a good outcome.
13,22,25,30-32
A recent
retrospective study by Lau et al
22
reported that the risk of
osteoarthritis is dependent on the quality of the reduction.
A good reduction has an 18.2 times decreased risk of
severe osteoarthritis compared with a fair or poor
reduction. Similarly, Adib et al
33
found that in patients
with an anatomical reduction, 35% developed
osteoarthritis, compared with 80% of those who had a
non-anatomical reduction. We also found that functional
outcome improved significantly with the quality of the
reductio
n.
In our study, dorsal bridge plate fixation gave a better
functional outcome than screw fixation. Reported AOFAS
midfoot scores for functional outcome have ranged from
67.5 to 84 for screw fixation:13,32,34-37 these are consistent
with our findings. In 2014, Hu et al20 described a
prospective study of 60 patients which compared the
functional outcome in patients with a Lisfranc injury
treated by dorsal plating or transarticular screws. At short-
and medium-term follow-up, the AOFAS score was only
marginally better in the plate group (83.1 versus 78.5). A
recent retrospective study of 34 patients by van Koperen et
al21 also showed better AOFAS scores (77 versus 66) and
levels of patient satisfaction (90% versus 80%) for bridge
plate fixation than screw fixation, but no statistical
significance was reported. Their results were potentially
confounded by the inclusion of patients treated with a
combination of techniques within the bridge plate group. In
addition, no analysis of anatomical reduction was
undertaken. In our study, a trend was noted which
suggested that plate fixation is associated with improved
anatomical reduction, although this did not achieve
statistical significance (p = 0.06). This was probably due to
the small sample size. We suspect the improved functional
outcomes in the plate fixation group may be related to the
improved maintenance of anatomical reduction. Another
potential consideration is that by avoiding further damage
to the articular surface, bridge plating results in less
arthrosis thereby improving the functional outcome.
Considerably worse functional outcomes were seen
when a combination of plating and screws were used. There
are several potential explanations for this, all of which are
probably due to the severity of the initial injury. Firstly, a
greater proportion of Myerson type A and C2 injuries were
treated with the combination technique (52%), than by
plating (16%) or screw fixation (34%). Secondly, the
combination group had a greater mean number of columns
fixed (2.5) compared with the plate group (1.9) and screw
group (2.1). This study showed that the outcome is
significantly worse when three columns have to be fixed.
When more than one column has to be fixed, a more
extensive soft-tissue dissection is needed which may result
in greater scarring. Lastly, compounding the above issues is
the use of transarticular screws, often through several
joints, which results in increased articular damage and
potentially more severe arthrosis.
Several classification systems for Lisfranc joint injuries
are currently in use.24,38 To date, minimal evidence exists to
show that these systems are predictors of outcome. In this
study, we used the Myerson classification. In 2014, a
retrospective study by Yu et al39 of 80 patients with
Lisfranc injuries and a mean follow-up of 24 months
showed a statistically significant difference in functional
outcome between Myerson type B (homolateral incomplete
medially or laterally) compared with Myerson types A
(homolateral complete) and C (divergent partially or
completely). The results of our study agree with these
findings in showing a significantly worse functional
outcome in the types A and C2 than in types B1, B2, and
C1. This was consistent across all three treatment groups,
suggesting that complete Lisfranc injuries, either
homolateral or divergent, have considerably worse
outcomes whichever method of treatment is used.
Table V. Complications by type of surgery
Operative type Soft-tissue injury or infection Pain Nonunion or malunion Malfixation Total
Screws, n (%) 5 (13)4 (11)1 (3)0 (0) 10 (26)
Plates, n (%) 6 (13)1 (2)0 (0)4 (9) 11 (24)
Combination, n (%) 2 (8)9 (36)1 (4)3 (12) 15 (60)
DORSAL BRIDGE PLATING OR TRANSARTICULAR SCREWS FOR LISFRANC FRACTURE DISLOCATIONS 473
VOL. 100-B, No. 4, APRIL 2018
A proposed drawback of plate fixation is the potential
need for greater dissection, which may lead to higher rates
of infection and stiffness. Bridge plating caused more
paraesthesiae of the DPN, although patient satisfaction was
not compromised. In this study, surgical site infection
occurred more commonly in the transarticular screw group
(8%) than in the plate group (4%): this concurs with
previous studies.20,21 Notably, a lower infection rate
occurred in a group with a higher proportion of smokers.
Complications, particularly problems with severe pain
which occurred in 36% of patients, occurred most
frequently in the combination group.
This study has a number of limitations. It is primarily
limited by its retrospective nature and the possibility that
bias occurred in the allocation of patients to differing
treatment groups. Despite this potential drawback, the
three groups had similar patient demographics and
proportion of open injuries. There was, however, a slightly
greater proportion of complete (Myerson A and C) injuries
in the combination fixation group and a greater number of
columns needing to be fixed. This may have affected the
results of this particular group but does not appear to have
affected any direct comparison between screw and plating
groups. There was a shorter duration of follow-up in the
plate fixation group which reflects the fact that this is a
relatively new technique. There is a possibility that if results
deteriorate over time that the improved functional outcome
seen in this group will become diluted. This needs to be
addressed by a prospective study. Similarly, radiological
follow-up was not of sufficient duration to determine
whether the prevention of secondary damage to the
articular surface leads to less post-traumatic arthritis: this
also merits further investigation. Finally, the relatively
small sample size, although still larger than other
comparable studies, limited the statistical power of some of
our results.
In conclusion, bridge plate fixation for Lisfranc injuries
gives a better functional outcome and quality of reduction
than transarticular fixation or a combination of the two
techniques. Anatomical reduction gives a better functional
outcome independent of the fixation technique. A
combination technique is associated with a significantly
poorer outcome, although this may, in part, be secondary
to selection bias, with a trend noted towards more severe
injuries in this group. Primary arthrodesis may be a
preferred option for more severe injuries such as those of
Myerson types A and C2.
Take home message:
- Bridge plate fixation for Lisfranc injuries showed improved
functional outcomes and quality of reduction compared to
transarticular screw fixation or a combination technique
- Better functional outcomes were also seen with anatomic reduction,
independent of the fixation technique
- Complete Lisfranc injuries, either hom olateral or divergent, result in con-
siderably worse outcomes independent of the treatment modality
Twitter
Follow N. Kirzner @Nathan_Kirzner
Follow H. Bedi @OSVresearchunit
References
1. Siddiqui NA, Galizia MS, Almusa E, Omar IM. Evaluation of the tarsometatarsal
joint using conventional radiography, CT, and MR imaging. Radiographics
2014;34:514–531.
2. Lewis JS Jr, Anderson RB. Lisfranc Injuries in the Athlete. Foot Ankle Int
2016;37:1374–1380.
3. Krause F, Schmid T, Weber M. Current Swiss techniques in management of
Lisfranc injuries of the foot. Foot Ankle Clin 2016;21:335–350.
4. Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current
concepts. J Am Acad Orthop Surg 2010;18:718–728.
5. Desmond EA, Chou LB. Current concepts review: Lisfranc injuries. Foot Ankle Int
2006;27:653–660.
6. Vuori JP, Aro HT. Lisfranc joint injuries: trauma mechanisms and associated
injuries. J Trauma 1993;35:40–45.
7. Stavlas P, Roberts CS, Xypnitos FN, Giannoudis PV. The role of reduction and
internal fixation of Lisfranc fracture-dislocations: a systematic review of the
literature. Int Orthop 2010;34:1083–1091.
8. Schildhauer TA, Nork SE, Sangeorzan BJ. Temporary bridge platin g of the medial
column in severe midfoot injuries. J Orthop Trauma 2003;17:513–520.
9. Puna RA, Tomlinson MP. The role of percutaneous reduction and fixation of
Lisfranc injuries. Foot Ankle Clin 2017;22:15–34.
10. Ho ng CC, Pearce CJ, Ballal MS, Calder JD. Management of sports injuries of the
foot and ankle: an update. Bone Joint J 2016;98-B:1299–1311.
11. Smith N, Stone C, Furey A. Does open reduction and internal fixation versus
primary arthrodesis improve patient outcomes for Lisfranc trauma? A systematic
review and meta-analysis. Clin Orthop Relat Res 2016;474:1445–1452.
12. Weatherford BM, Bohay DR, Anderson JG. Open reduction and internal fixation
versus primary arthrodesis for Lisfranc injuries. Foot Ankle Clin 2017;22:1–14.
13. Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and
internal fixation of Lisfranc joint injuries. J Bone Joint Surg [Am] 2000;82-A:1609–
1618.
14. Be llabarba C, Barei D, Sanders R. Dislocations of the foot. In: Coughlin MJ, Mann
RA, Saltzman CL, eds. Surgery of the Foot and Ankle. Eighth ed. Philadelphia: Mosby,
year: 2137–2197.
15. Eleftheriou K. Lisfranc injuries - an update. Knee Surg Sports Traumatol Arthrosc
2013;21:1434–1446.
16. Deol R. Return to play after Lisfranc injuries. Am J Sports Med 2016;44:166–170.
17. Alberta FG, Aronow MS, Barrero M, et al. Ligamentous Lisfranc joint injuries: a
biomechanical comparison of dorsal plate and transarticular screw fixation. Foot
Ankle Int 2005;26:462–473.
18. Ga ines RJ, Wright G, Stewart J. Injury to the tarsometatarsal joint complex during
fixation of Lisfranc fracture d islocations: an anatomic study. J Trauma 2009;66:1125–
1128.
19. Marks RM, Parks BG, Schon LC. Midfoot fusion technique for neuroarthropathic
feet: biomechanical analysis and rationale. Foot Ankle Int 1998;19:507–510.
20. Hu SJ, Chang SM, Li XH, Yu GR. Outcome comparison of Lisfranc injuries treated
through dorsal plate fixation versus screw fixation. Acta Ortop Bras 2014;22:315–320.
21. van Koperen PJ, de Jong VM, Luitse JS, Schepers T. Functional outcomes after
temporary bridging with locking plates in Lisfranc injuries. J Foot Ankle Surg
2016;55:922–926.
22. Lau S, Howells N, Millar M, et al. Plates, screws, or combination? radiologic
outcomes after Lisfranc fracture dislocation. J Foot Ankle Surg 2016;55:799–802.
23. Strotman PK, Reif TJ, and Pinzur MS. Charcot arthropathy of the foot and ankle.
Foot Ank Int 2016;37:1255–1263.
24. Myerson MS. The diagnosis and treatment of injury to the tarsometatarsal joint
complex. J Bone Joint Surg [Br] 1999;81-B:756–763.
25. Komenda GA, Myerson MS, Biddinger KR. Results of arthrodesis of the
tarsometatarsal joints after traumatic injury. J Bone Joint Surg [Am] 1996;78-A:1665 –
1676.
26. Schepers T, Oprel PP, Van Lieshout EM. Influence of approach and implant on
reduction accuracy and stability in lisfranc fracture-dislocation at the tarsometatarsal
joint. Foot Ankle Int2013;34:705–710.
27. Kitaoka HB, Alexander IJ, Adelaar RS, et al. Clinical rat ing systems for the ankle-
hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 1994;15:349–353.
28. Morley D, Jenkinson C, Doll H, et al. The Manchester-Oxford Foot Questionnaire
(MOXFQ): development and validation of a summary index score. Bone Joint Res
2013;2:66–69.
474 N. KIRZNER, P. ZOTOV, D. GOLDBLOOM, H. CURRY, H. BEDI
Follow us @BoneJointJ THE BONE & JOINT JOURNAL
29. Wilppula E. Tarsometatarsal fracture-dislocation. Late results in 26 patients. Acta
Orthop Scand 1973;44:335–345.
30. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the
tarsometatarsal joints: end results correlated with pathology and treatment. Foot
Ankle 1986;6:225–242.
31. Raikin SM, Elias I, Dheer S, et al. Prediction of midfoot instability in the subtle
Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative
findings. J Bone Joint Surg [Am] 2009;91-A:892–899.
32. Ghate SD, Sistla VM, Nemade V, et al. Screw and wire fixation for Lisfranc
fracture dislocations. J Orthop Surg (Hong Kong) 2012;20:170–175.
33. Adib F, Medadi F, Guidi E, Alami Harandi A, Reddy C. Osteoarthritis following
open reduction and internal f ixation of the Lisfranc injury. 12th EFORT Congre ss, 2011.
J Bone Joint Surg [Br] 2012;94-B(Suppl XXXVII):5.
34. Perugia D, Basile A, Battaglia A, Stopponi M, De Simeonibus AU. Fracture
dislocations of Lisfranc's joint treated with closed reduction and percutaneous
fixation. Int Orthop 2003;27:30–35.
35. Ly TV, Coetzee JC. 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-A:514–520.
36. Abbasian MR, Paradies F, Weber M, Krause F. Temporary internal fixation for
ligamentous and osseous Lisfranc injuries: outcome and technical tip. Foot Ankle Int
2015;36:976–983.
37. Rajapakse B, Edwards A, Hong T. A single surgeon's experience of treatment of
Lisfranc joint injuries. Injury2006;37:914–921.
38. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to
the TMT joint: incidence, classification and treatment. J Bone Joint Surg [Br] 1982;64-
B:349–356.
39. Yu X, Pang QJ, Yang CC. Functional outcome of tarsometatarsal joint fracture
dislocation managed according to Myerson classification. Pak J Med Sci
2014;30:773–777.
Author contributions:
N. Kirzner: Literature search, Designing the study, Collecting, analyzing, and
interpreting the data, Writing and critically revising the manuscript.
P. Zotov: Analyzing the data, Writing the manuscript.
D. Goldbloom: Analyzing the data, Critically revising the manuscript, Provi-
sion of surgical cases.
H. Curry: Analyzing the data, Critically revising the manuscript, Provision of
surgical cases.
H. Bedi: Writing and critically revising the manuscript, Provision of surgical
cases.
Funding statement:
No benefits in any form have been received or will be received from a
commercial party related directly or indirectly to the subject of this article.
Acknowledgements:
The authors thank Associate Professor Susan Liew and Eldho Paul for their
assistance.
This is an open-access article distributed under the terms of the Creative
Commons Attributions license (CC-BY-NC), which permits unrestricted use,
distribution, and reproduction in any medium, but not for commercial gain,
provided the original author and source are credited.
This article was primary edited by A. C. Ross.
... These injuries result from axial loading, excessive supination or pronation of the plantar flexed foot (1). They are relatively rare accounting for only 0.2% of fractures annually (2) and optimal reduction of Lis Franc injuries results in less arthritis with better long-term outcomes (3). ...
... Whilst previous biochemical studies show stronger fixation with compression plates (20). Rigid stabilization may confer longer-term benefits as functional outcomes are statistically better in all domains of the MOXFQ and equivalent or better than those shown by other authors (3). Anecdotally, in our series removal of hardware had a small observed improvement in MOXFQ results (n = 8) but did not hinder outcomes. ...
... remain unclassified.ARTICLE IN PRESSarticular fixation leads to inferior result in the short-term. Hu et al (2014) (17) showed a better outcome and a lower re-operation rate with bridge plating than standard screw fixation. Whilst patient satisfaction is noted to be higher with bridge plating (90%) vs trans-articular screw fixation group (80%)(18).Kirzner et al (2018) (3) concluded bridge plate fixation leads to a better functional outcome than transarticular fixation or a combination of the 2 techniques. ...
Article
This retrospective case series aimed to identify whether trans-articular screws, dorsal bridging plates or if a 4-corner compression plate offers better functional outcome after B2 Lis Franc injuries. Thirty-eight patients underwent surgical fixation for these injuries over five years in a Level 1 Trauma Centre. Patients were treated in 1 of 3 treatment arms: trans-articular screw, dorsal bridge plate, or 4-corner compression plate fixation. The primary outcome measures were the Manchester Oxford Foot and Ankle Questionnaire and the Euroqol- 5DL score and surgical results included postoperative complications and further surgery. Injury type, energy of mechanism, open versus closed status were not significantly different within any fixation group. We achieved 94.7% (n=36) good anatomical reduction. Finding significant improvement between plate fixation (both types) versus trans-articular screw groups treatment functional outcomes. A clinically crucial improvement in Manchester Oxford Foot & Ankle Questionnaire scores, and improved Euroqol- 5DL outcomes between 4-corner compression plate and trans-articular screw group. Overall, there was no significant difference in metalware failure, metalware removal and soft tissue complications. This study concludes that functional outcomes after Lis Franc fractures are not just dependant on the quality of anatomical reduction but are affected by fixation type. Further studies are required to provide qualitative analysis and assessment of dorsal bridge plate fixation versus 4-corner compression plate. Significantly, we have seen the 4-corner compression plate group reached the minimum clinically meaningful difference in the Manchester Oxford Foot and Ankle Questionnaire when compared to trans-articular screw fixation. Level of Clinical Evidence: 4
... According to most authors, PA has better results in terms of function and clinical outcomes compared to ORIF treatment with TAS and with a combination of the two techniques [11,42,43]. ...
... In a comparison study [42] patients treated with DP showed better functional and radiological outcomes than those treated with TAS or a combination technique. The DP group had a mean AOFAS score of 82.5 points, compared with 71.0 for the TAS group and 63.3 for the combination group (P<0.001). ...
Article
Full-text available
Lisfranc complex injuries are a spectrum of midfoot and tarsometatarsal (TMT) joint trauma, more frequent in men and in the third decade of life. Depending on the severity of the trauma can range from purely ligamentous injuries, in low-energy trauma, to bone fracture-dislocations in high-energy trauma. A quick and careful diagnosis is crucial to optimize management and treatment, reducing complications and improving functional outcomes in the middle and long-term. Up to 20% of Lisfranc fractures are unnoticed or diagnosed late, above all low-energy trauma, mistaken for simple midfoot sprains. Therefore serious complications such as post-traumatic osteoarthritis and foot deformities are not uncommon. Clinically presenting with evident swelling of the midfoot and pain, often associated with joint instability of the midfoot. Plantar region ecchymosis is highly peculiar. First level of examination is X-Ray performed in 3 projections. CT scan is useful to detect nondisplaced fractures and minimal bone sub-dislocation. MRI is the gold standard for ligament injuries. The major current controversies in literature concern the management and treatment. In stable lesions and in those without dislocation, conservative treatment with immobilization and no weight-bearing is indicated for a period of 6 weeks. Displaced injuries have worse outcomes and require surgical treatment with the two main objectives of anatomical reduction and stability of the first three cuneiform-metatarsal joints. Different surgical procedures have been proposed from closed reduction and percutaneous surgery with K-wire or external fixation (EF), to open reduction and internal fixation (ORIF) with transarticular screw (TAS), to primary arthrodesis (PA) with dorsal plate (DP), up to a combination of these last 2 techniques. There is no superiority of one technique over the other, but what determines the post-operative outcomes is rather the anatomical reduction. However, the severity of the injury and a quick diagnosis are the main determinant of the biomechanical and functional long-term outcomes.
... 6)(7)(30)(35)(37)(38)(39)(40)(41)(42) . De estos 3 mencionan la variable calidad de reducción para lo cual usan los criterios radiográficos de Stein(42,43) en un estudio prospectivo de 30 meses encontrando diferencias en el puntaje entre reducción anatómica 79.3, vs reduc- ...
Article
Full-text available
Abstract: A Lisfranc injury compromises the tarsometatarsal joint, its structural keystone being the second metatarsal base. METHODS: This retrospective study collected data from ten patients who underwent surgery between January 2016 and March 2019. At least two radiographic views were obtained from preoperative radiographs and postoperative follow-up. Then, the quality of anatomic reduction was determined using the Wilppula classification, while function outcome was assessed with the AOFAS Midfoot Scale. RESULTS: The average age of patients in the study was 33.1 years old and nine patients were male. Nine patients had a Myerson type B2 Lisfranc injury, while one had a type B1. The average waiting time for surgery was 27.2 days, but one patient underwent surgery after 95 days. Patients had a mean postoperative follow-up period of 21.7 months. Cannulated screws (n=4), cortical screws (n=5) and cancellous screws (n=1) were used for bone fixation. Six patients showed very good results equal to or above 80 on the AOFAS scale and the overall average was 78.9 ± 4,21. A difference was observed between the average AOFAS score of the group with good anatomic reduction (n=7; 80.9 ± 3.54) and the one with regular reduction (n=3; 75.3 ± 1.53). No differences were found for the type of material used for bone fixation or the waiting time for surgery. CONCLUSIONS: The population under study showed good functional and anatomic outcome in comparison with other case-series studies, despite the limitations such as long waiting times for surgery and unavailability of materials for bone fixation. Keywords: Lisfranc injuries, open reduction and internal fixation, screws, tarsometatarsal
... Later in 2018, Kirzner et al. [16] reported on 150 patients randomized to the same three fixation methods. There was significantly better functional outcome in the bridge plate group. ...
Article
Full-text available
Background: Lisfranc injuries are complex and serious. When surgery is indicated, open reduction and internal fixation is usually the treatment of choice. There are different methods of fixation ranging from intra-articular screw fixation to bridge plate fixation. Patients and methods: We retrospectively reviewed a consecutive series of 23 patients who underwent memory staple fixation of Lisfranc injuries at a Level 1 major trauma centre. Patients were followed up at regular intervals after operation, with clinical and radiographic assessment of progress of healing and any complications. Clinical and functional outcomes were assessed at an average of 12 months. Functional outcomes were assessed by the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scores. Results: At the end of the follow-up, the mean AOFAS midfoot score was 78.65 (S.D-17.45, 95%CI-69.49-80.3). Excellent outcome (score ≥90) was obtained in six patients, good (90> score ≥75) in seven patients, fair (75> score ≥50) in eight patients and poor (score≤49) in two patients. Gender and associated injuries did not show any statistical difference in AOFAS midfoot scores but there was some relation with poorer outcomes in patients who had broken staples (p=0.003). Conclusions: we believe that this is the largest series on staple fixation for Lisfranc injuries. The use of staple fixation involves simple technique with satisfactory fixation and good functional outcomes.
... In addition, Lau et al., in two different studies found no significant difference when comparing plate versus screw fixation outcomes and concluded that the functional outcomes related to quality of anatomical reduction not the implant of fixation [38,43]. Kirzner et al. [44], reported that there was better functional outcome and quality of reduction in patients managed with plate fixation than transarticular screw fixation or a combination of the two techniques. In a recent systematic review, Philpott et al. [45], found that superior functional outcomes with use of bridge plate fixation was reported by only a small number of studies. ...
Article
Background The studies evaluating the outcomes of treatment of purely ligamentous unstable Lisfranc injuries are scarce. This study aimed at comparing outcomes of primary tarso-metatarsal joints fusion versus open reduction and internal fixation in treatment of such condition and determining the possible factors that may alter the outcomes. Methods This study comprised 30 patients; 16 in fusion group and 14 in ORIF group. One column was operated on in 2 patients, two columns in 21, and three columns in 7. The mean follow-up period was 36 months. Results There was no statistically significant difference between both groups regarding patients or injury characteristics. The mean AOFAS and FFI-Rs scores were 88.9 and 22.7 in the fusion group, compared to 61.7 and 34.5 in the ORIF group (P =.03,.04 respectively). At final follow-up all patients in the primary arthrodesis group were maintaining an anatomical reduction versus 71.5% in the ORIF group. Sixteen patients (53%) reported prominent hardware troubles that required removal. Five patients in ORIF group developed osteoarthritis, and four of them underwent secondary fusion. There was significantly higher incidence of posttraumatic osteoarthritis in patients with non-anatomical reduction and complete injuries. Better mean AOFAS and FFI-Rs scores occurred with non-smokers and with anatomical reduction. Conclusion Based on this limited case series, purely ligamentous Lisfranc injuries were found to have better outcomes when managed with a primary fusion as compared to ORIF. Achieving and maintaining anatomical reduction was the most important factor that is significantly attributed to improved outcomes. Possible arthritic changes and additional surgeries apart from implant removal could be avoided by primary fusion. Level of evidence level I- prospective comparative case study.
... One way to avoid additional damage to the joints' cartilage by K-wires or screws is by temporary joint stabilization using a bridging plate. It could already be demonstrated that this method resulted in better functional and radiological outcomes compared with transarticular screws [12]. The disadvantages of this procedure could be a higher soft tissue dissection. ...
Article
Full-text available
Purpose Lisfranc injuries are rare and often pose a challenge for surgeons, particularly in initially missed or neglected cases. The evidence on which subtypes of Lisfranc injuries are suitable for conservative treatment or should undergo surgery is low. The aim of this study was to retrospectively analyze treatment decisions of Lisfranc injuries and the clinical outcome of these patients within the last ten years. Methods All patients treated due to a Lisfranc injury in a German level I trauma centre from January 2011 until December 2020 were included in this study. Radiologic images and medical data from the patient files were analyzed concerning the classification of injury, specific radiologic variables, such as the Buehren criteria, patient baseline characteristics, and patient outcome reported with the Foot Function Index (FFI). Results Ninety-nine patients were included in this study (conservative = 20, operative = 79). The overall clinical outcome assessed by the FFI was good (FFI sum 23.93, SD 24.93); patients that were identified as suitable for conservative treatment did not show inferior functional results. Qualitative radiological factors like the grade of displacement and the trauma mechanism were more strongly associated with the decision for surgical treatment than quantitative radiologic factors such as the distance from the first to the second metatarsal bone. Conclusion If the indication for conservative or operative treatment of Lisfranc injuries is determined correctly, the clinical outcome can be comparable. These decisions should be based on several factors including quantitative and qualitative radiologic criteria, as well as the trauma mechanism.
Article
Background: Open reduction and internal fixation (ORIF) is a popular method for treatment of displaced Lisfranc injuries. However, even with anatomic reduction and solid internal fixation, treatment does not provide good outcomes in certain severe dislocations. The purpose of this study was to compare ORIF and primary arthrodesis (PA) of the first tarsometatarsal (TMT) joint for Lisfranc injuries with the first TMT joint dislocation. Methods: Seventy-eight Lisfranc injuries with first TMT joint dislocation were finally enrolled and analyzed in a prospective, randomized trial comparing ORIF and PA. They were 50 males and females with a mean age of 40.7 years and randomized to ORIF group and PA group. Outcome measures included radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, Foot and Ankle Ability Measure (FAAM) Sports subscale, visual analog scale (VAS), and the 36-Item Short Form Health Survey (SF-36). Complications and revision rate were also analyzed. Results: Forty patients were treated by ORIF, while PA group includes 38 cases. Patients were followed up for 37.8(range, 24-48) months. At final follow-up, the mean AOFAS midfoot score (P < 0.01), the FAAM Sports subscale (P < 0.01), the physical function score (P < 0.05), and the Bodily Pain score of SF-36 (P < 0.05) after ORIF treatment were significantly lower than PA group. The mean VAS score in ORIF group was higher (P < 0.01). In ORIF group, redislocation of the first TMT joint was observed in ten cases, and thirteen patients had pain in midfoot. No redislocation and no hardware failure were identified in PA group. Conclusion: PA of the first TMT joint provided a better medium-term outcome than ORIF for Lisfranc injuries with the first TMT dislocation. Possible complications and revision could be avoided by PA for dislocated first ray injuries.
Article
Lisfranc joint injury is uncommon and can fail to notice at the initial assessment and treatment. Once ignored, late reduction is difficult and requires extensive dissection. Lisfranc joint injuries are known to result in unctional loss and chronic pain due to residual ligamentous instability, deformity, and/or arthritis; osteoporosis may also occur due to antalgic gait without weight bearing. This recognition is important, as most of the injuries are either misdiagnosed or overlooked, such as in patients suffering from polytraumatic injuries, possibly becoming a permanent source of pain after the major fractures have healed. A prospective study to be conducted at the Department of Orthopaedic Surgery, Vijayanagar Institute of Medical Sciences, Ballari from 2018 to 2020. This study consists of 30 cases of Lisfranc’s Fracture Dislocation treated operatively by Cannulated Cancellous Screws and K wires (Kirschner Wires). The cases were selected according to inclusion and exclusion criteria. The functional outcome was evaluated using AOFAS score. In our study, we achieved Excellent in 10% of the cases. Good outcome in 73.33% of cases, Fair outcome in 13.3% of the cases and no patient had poor outcome in our study. Average AOFAS (American Orthopaedic Foot and Ankle Score) being 76.5. It can be concluded from the present study that operative management with CC (Cannulated Cancellous Screws) Screws and K Wires is an effective means of treatment based on biomechanical principle with good functional outcome and minimum complication.
Article
The optimal treatment strategy of Lisfranc injury is still in debate. This study aimed to compare the functional outcome and complications of dorsal bridge plating (BP) and transarticular screws (TAS). A systematic review and meta-analysis of the present literature was performed. PubMed, EMBASE and Cochrane databases were searched using set search criteria and date range January 2000 to July 26, 2021. Randomized controlled trials (RCTs) and observational comparative studies concerning the outcome of dorsal BP and TAS for the fixation of Lisfranc injuries were eligible for inclusion. Random effect models were used to analyze pooled data. Forest plots using 95% confidence intervals (CI) were created to illustrate mean differences and odds ratios. Four observational studies were eligible for inclusion, including 111 patients in the BP group and 87 patients in the TAS group. American Orthopaedic Foot & Ankle Society (AOFAS) score was significantly higher in the BP group (mean difference 7.08, 95% CI 1.50 - 12.66, p = 0.01). Osteoarthritis was significantly less common in the BP group compared to the TAS group (odds ratio 0.45, 95% CI 0.22 - 0.94, p = 0.03). No significant difference was found between the groups in terms of postoperative infection, hardware removal, chronic pain and secondary arthrodesis. Dorsal bridge plating of fractures in the Lisfranc joint may lead to better functional outcome and a lower incidence of post-traumatic arthritis when compared to transarticular screws. A larger body of high-quality evidence is required to independently analyze the severity of fractures in the different columns involved and subsequent outcomes of operative management. Level of clinical evidence 3
Article
No consensus exists regarding whether metalwork should be routinely removed following fixation of a Lisfranc injury. When metalwork is removed, notable variation in the timing of surgery is reported in current literature. With the support of the British Orthopaedic Foot & Ankle Society (BOFAS) and the Orthopaedic Trauma Society (OTS) an online 10-question survey was distributed and completed by a total of 205 consultant surgeons in the UK between April – June 2020. Excluding the 20 consultant responses from a regional pilot survey, 185 responses were used to form the main analysis. Over one third (69/183, 37.7%) of surgeons reported they routinely remove metalwork following Lisfranc injury fixation at a median time of 6 months post fixation (interquartile range 4-10). The two most commonly chosen reasons for removal of metalwork were ‘to optimise physiological function’ and ‘to reduce the risk of broken metalwork and risk of making subsequent surgery more difficult’ (55/78 responses, 70.5%). Over two thirds of survey respondents (126/184, 68.5%) expressed interest to participate in a randomised controlled trial to compare outcomes of metalwork retention versus removal following Lisfranc injury fixation. Community clinical equipoise exists nationally regarding routine metalwork removal following Lisfranc injury fixation. Considering the paucity of literature, the current survey supports the development of a randomised controlled trial to establish the risks and benefits of metalwork retention versus removal, and would be of value to foot & ankle and trauma surgeons in the UK.
Article
Full-text available
Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration. In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:1299–1311.
Article
Full-text available
Level of evidence: Level V, expert opinion.
Article
Full-text available
Sporting injuries around the ankle vary from simple sprains that will resolve spontaneously within a few days to severe injuries which may never fully recover and may threaten the career of a professional athlete. Some of these injuries can be easily overlooked altogether or misdiagnosed with potentially devastating effects on future performance. In this review article, we cover some of the common and important sporting injuries involving the ankle including updates on their management and outcomes. Cite this article: Bone Joint J 2016;98-B:874–83.
Article
To be able to perform percutaneous fixation of Lisfranc injuries, this article emphasizes that an anatomic reduction must be mandatory. When uncertainty remains as to whether closed reduction is anatomic, formal open reduction is recommended because accuracy of reduction is correlated with long-term outcome. Closed injuries with minimal displacement, bony avulsions, and skeletally immature individuals seem the most appropriate indications for percutaneous fixation. Not all injuries are ideal for this method of treatment, and this is an area that needs to be more clearly defined in the future.
Article
Management of injuries to the tarsometatarsal (Lisfranc) joint complex continues to generate heated debate. Arthrodesis of the Lisfranc joint complex has historically been reserved as a salvage procedure for failed treatment. Recently, primary arthrodesis has emerged as a viable treatment alternative to open reduction and internal fixation for these injuries. The objective of this article was to examine the current literature regarding open reduction and internal fixation versus primary arthrodesis of Lisfranc injuries.
Article
Lisfranc injuries to the tarsometatarsal complex of the midfoot have become increasingly recognized in the athletic population. Regardless of mechanism, any injury that results in instability in the midfoot requires operative stabilization to preserve function and enable return to sport. In this manuscript, the anatomy, etiology, prevalence, current treatment modalities, and clinical outcomes of patients who suffer Lisfranc injuries are reviewed, with a special focus on the unique characteristics surrounding such an injury in an athlete. Level of Evidence: Level V, expert opinion.
Article
The standard operative treatment of Lisfranc fracture dislocations currently consists of open reduction and transarticular fixation. Recently, bridge plating has been used more often. Using joint spanning, the reduced fracture dislocation is temporary stabilized to minimize articular damage. The present study describes the outcomes of patients treated with bridge plating after tarsometatarsal fracture dislocations compared with transarticular screw fixation. A retrospective cohort study was performed. Patients with an isolated tarsometatarsal injury who had been treated operatively from June 2000 to October 2013 were included. The primary functional outcome was measured using the American Orthopaedic Foot and Ankle Society midfoot score and the Foot Function Index. The secondary outcome was patient satisfaction, which was measured using the EuroQol 5 dimensions questionnaire and a visual analog scale. A total of 34 patients were included. Bridge plating was used in 21 patients. In 13 patients, Kirschner wires or transarticular screws or a combination were used. The median follow-up period was 49 (interquartile range 18 to 89) months. The implants were removed in 10 of 13 patients in the transarticular group and 17 of 21 patients in the bridge plating group. The incidence of wound complications was comparable in both groups. The median American Orthopaedic Foot and Ankle Society score was lower in the transarticular group (77 versus 66). The Foot Function Index score was 18 in both groups. Patient satisfaction was 90% in the bridge plating group and 80% in the transarticular group. Bridge plating for Lisfranc injuries led to at least similar results compared with transarticular fixation in terms of functional outcomes and patient satisfaction. Longer follow-up is necessary to determine whether the prevention of secondary damage to the articular surface leads to less post-traumatic arthritis and better functional outcomes.
Article
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.
Article
The outcome after Lisfranc injuries correlates with anatomic and stable reduction. The best surgical treatment, particularly for the ligamentous Lisfranc injuries, remains controversial. Recent publications suggest that the ligamentous injuries may benefit from primary partial Lisfranc arthrodesis. Most surgeons agree that an appropriate reduction is better and easier achieved by open reduction and stable temporary screw or dorsal plate fixation or by open primary partial arthrodesis than by closed reduction or Kirschner wire fixation. Despite correct surgical technique and postoperative management, symptom-free recovery is uncommon. This article outlines current techniques in the management of Lisfranc injuries and resultant postoperative outcomes in a level I trauma center.