Download Case study: Lisfranc stabilization - Fixos 2 and Anchorage

Case study: Lisfranc stabilization - Fixos 2 and Anchorage plating
A review by Vinod K Panchbhavi MD, FACS
Patient history:
This patient is a 35 year old avid
marathon runner who was involved
in a motor vehicle accident with her
right foot suddenly forced back on the
brake pedal. She noticed immediate
pain in the right midfoot. She was able
to progressively bear more weight on
her foot but with continued pain. She
waited, thinking it was a sprain, and
presented it to the clinic about three
weeks after the injury. She had not
had any treatment for it apart from
some pain relieving medications.
Assessment:
On evaluation she appeared to be in
good general health and had swelling
over the midfoot and bruising under
the midfoot in the region of the arch
of the foot along with point tenderness over midfoot in the region of the
first and second metatarso-cuneiform
joints. She had good dorsalis pedis
and posterior tibial pulse and intact
sensation. Weight bearing radiographs of both feet were obtained to
evaluate for Lisfranc ligament injury.
The radiographs showed diastasis
between the base of the second metatarsal and the middle cuneiform bone
along with a small fleck of bone in the
interval between these bones. A diagnosis of Lisfranc ligament and tarsometatarsal subluxation of the right
foot was confirmed by these findings.
Surgical intervention to stabilize the
unstable joints and reduce the diastasis at the Lisfranc joint was planned.
Procedure/treatment:
Under anesthesia, the foot was
stressed and fluroscopy to determine
which joints in the midfoot needed
stabilization. There was abnormal
opening at the first metatarso-cuneiform joint on abduction stress in addition to worsening of the diastasis at
the second metatarso-cuneifrom joint.
A dorsal open approach was used
to approach the articulation of the
first metatarso-cuneiform joint. The
capsule was found to be disrupted
and the joint unstable. This joint
was reduced and temporarily held
with 0.62 Kirschner wire. A locking
titanium four hole plate (Anchorage,
Stryker) was positioned over the
joint and after confirming appropriate positioning, fixed with two locking screws on either side of the joint.
A percutaneous approach one centimeter long, was made to the lateral
wall of the base of the second metatarsal using a ‘nick and spread’. A
bone holding clamp was then applied
to compress and reduce the diastasis
between the base of the second metatarsal and the medial cuneiform bone.
Then a guide wire for a 5.0 mm diameter, titanium threaded head partial
threaded screw was inserted from
the base of the second metatarsal
into the medial cuneiform bone. Over
this guide wire an appropriate length
screw was inserted to stabilize the
Lisfranc joint.
Figure 1
Discussion:
This patient is an avid marathon
runner and wishes to be able to continue to participate in races in the
future. She presented three weeks
after the injury. At this stage the surgical options that can be considered
were either arthrodesis or internal
fixation. On the radiographs obtained
there was a fleck or small fragment
off the base of the second metatarsal,
which makes this case not purely
ligamentous. A purely ligamentous
injury may have a poorer prognosis
resulting in non-healing of the Lisfranc ligament if the option of open
reduction and internal fixation is selected initially. Failure of fixation or
failure of healing may then require
arthrodesis in the future.
Figure 2
Figure 3
Figure 4
Although there is current literature
comparing transarticular internal
fixation with arthrodesis performed
as a primary procedure in such
cases1, there are no studies that compare internal fixation with bridging
techniques to arthrodesis.
Follow-up:
In this case extra-articular fixation
was used to preserve the joints. A
rigid stabilization was obtained with
use of a locking plate. The Lisfranc
joint itself was reduced and stabilized with a threaded head screw
which can potentially increase compression, provide stability and be
less prominent when compared to a
smooth headed screw. Metal artifact
distortion is less with the titanium if
evaluation with MRI scan becomes
necessary in the future.
Conclusion:
At four months following fixation,
the patient started to run and mentioned some initial discomfort which
resolved and she returned to her previous level of activity.
This patient, despite late presentation, appears to have healed her Lisfranc injury. Anatomic reduction and
rigid extra-articular stabilization of
the unstable tarsometatarsal articulations following a Lisfranc injury can
restore function after such an injury.
Post-operative clinical outcome:
Figure 5
Figure 6
1.
The patient was immobilized in a
splint and evaluated for first post
operative visit in 10 days and the
splint was changed to a cast. Patient
remained non-weight bearing for a
total period of six weeks. The cast
was removed and patient started
bearing weight protected in a removable boot and attended physical therapy for rehabilitation.
She was given a molded arch support
with a carbon plate insert to be used
after three months from surgery for
about 12 months. The follow up radiographs show that the hardware
is intact and there is no diastasis at
the site of Lisfranc ligament. The
soft tissue swelling has completely
abated, indicating again resolution
and healing of injury.
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized
study. Foot Ankle Int. 2009 Oct. 30(10):913-22. [Medline].
Foot & Ankle
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Content ID: FIX-CS-1, 08-2016
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