Internal brace construct to treat Lisfranc injuries provides flexible fixation
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Ligamentous Lisfranc injuries are characterized by a disruption between the articulation of the medial cuneiform and the base of the second metatarsal.
Ligamentous injuries can be either subtle or obvious and can also occur with tarsometatarsal (TMT) subluxations or dislocations. These injuries typically happen in athletic activity and are also seen with lower-energy falls. Conventional use of transarticular screws to repair Lisfranc ligament injuries has provided good outcomes; however, the screws are also believed to decrease the natural physiological movement of the Lisfranc joint. This article discusses the technique of Lisfranc internal brace fixation for treatment of Lisfranc injuries. The internal brace technique allows for less bone loss from drilling and for collagen ingrowth, and it can be used in conjunction with bridge plating techniques.
Historical perspective
Lisfranc fractures account for approximately 0.20% of all fractures and are caused by a variety of injuries to the TMT joint ranging from low-energy ligamentous sprains to high-energy motor vehicle accidents. However, this injury is missed within nearly 20% to 30% of multitrauma patients. As a result, the true incidence of these fractures may be underestimated.
Treatment of Lisfranc injuries has changed substantially in the past 30 years. Initial treatment with cast immobilization has evolved to open reduction and internal fixation, often using transarticular screws for fixation. However, there have been reports of complications with transarticular screws, including damage to articular cartilage, loosening, hardware failure and skin irritation prompting a high implant removal rate. Flexible fixation methods have the theoretical advantage of decreased articular cartilage disruption, preservation of physiological motion and a lower implant removal rate.
The contraindications to surgical intervention include underlying infection, significant soft tissue swelling and severe peripheral vascular disease or fracture due to nerve dysfunction, such as Charcot neuropathy. Also, comminuted fractures without underlying bone stock are contraindicated for this technique.
Exposure and reduction technique
After induction of general anesthesia, an exam is performed using C-arm fluoroscopy. Manipulation of the foot is used to demonstrate instability and opening at the Lisfranc joint compared with the contralateral side (Figures 1, 2).
Source: Eric Giza, MD
A 2-cm to 4-cm incision is made just lateral to the lateral border of the second metatarsal. It is recommended to use fluoroscopy to mark this incision, as a common error is to be too medial over the second metatarsal shaft, thus making it difficult to work on the lateral border of the metatarsal without causing undue stretch to the soft tissues or extending the incision. Careful scissor dissection is performed down to bone. Hemostasis is achieved with electrocautery. Any branches of the superficial peroneal nerve are protected. The extensor hallucis brevis is bluntly retracted medially, thus protecting the neurovascular bundle.
The soft tissues are then elevated from lateral to medial toward the Lisfranc region. A portion of the dorsal Lisfranc ligament may be visualized running obliquely from the medial cuneiform to the second metatarsal. These oblique fibers may be disrupted following an acute tear or be homogenous and lacking direction following a chronic, scarred injury.
A freer elevator is placed in the articulation of the Lisfranc (Figure 3) and confirmed on fluoroscopy. Normally, the freer elevator will not pass between the medial cuneiform and second metatarsal, but in the case of a tear, it will pass easily. Intercuneiform disruption can be assessed in a similar manner as the freer should not pass between the medial and intermediate cuneiforms. If there is dorsal to plantar TMT or intercuneiform instability, this would need to be addressed separately with a bridge plating construct. After confirmation of isolated ligamentous Lisfranc injury, debris is removed from the joint. At this time, any bridge plating for TMT subluxations can be performed.
A percutaneous incision is then made at the border of the medial cuneiform and the joint is reduced with a large clamp in the direction of the Lisfranc joint (Figure 4). Fluoroscopy is used to confirm reduction (Figure 5). Ensure the clamping has not caused any subluxation of the TMT joints.
Lisfranc repair with internal brace
A 1.6-mm specialized passing wire is placed laterally at the base of the second metatarsal just distal to the articulation with the third metatarsal base. It is advanced through the second metatarsal base into the medial cuneiform under fluoroscopic guidance in line with the trajectory of the Lisfranc ligaments (Figure 6). The ideal wire exit point on the medial cuneiform is slightly dorsal to midline, plantar and proximal to the obliquely crossing tibialis anterior tendon. The wire is advanced through the medial cuneiform to the medial skin. A 1-cm to 2-cm incision is made to allow the wire to pass. Next, a 3.5-mm cannulated drill is placed over the medial portion of this wire to back-drill approximately 13 mm into the medial cuneiform for the interference screw (Figure 7). Fluoroscopy is used to confirm the lateral cortex of the medial cuneiform is not violated by the drill. If bone quality is outstanding, the wire is then pulled back and a 4.75-mm tap is advanced into the cuneiform approximately 7 mm.
The ultra-high strength FiberTape (Arthrex) is then threaded through a small stainless-steel button. The 2-mm FiberTape/button construct is then passed from lateral to medial using a passing wire (Figure 8). It is important to use the oscillate function on the drill when passing the ultra-high strength 2-mm tape and wire through the bone tunnel. Ensure that there is excellent apposition of the small button at the lateral second metatarsal. Pull tightly while diverging the suture limbs away from each other. Place a 4.75-mm x 15-mm polyether-ether-ketone (PEEK) interference screw between the limbs and advance it until the end of the screw is level with the medial cortex (Figure 9).
Dissection, retraction
Next, bluntly dissect from the lateral border of the middle cuneiform to the interference screw. The extensor hallicus longus, neurovascular bundle and tibialis anterior are retracted dorsally and the limbs of the ultra-high strength 2-mm tape are passed immediately dorsal to bone into the dorsal wound (Figure 10). A drill hole is made in the center of the middle cuneiform for the fully threaded, knotless 3.5-mm SwiveLock anchor (Arthrex). The suture limbs are placed on tension and secured into the drill hole with the interference screw (Figure 11). The remaining suture is cut.
Remove the clamp and confirm stability by stressing the joint under direct visualization (Figure 12). Attempts to pass a freer elevator into the joint should no longer be possible. Furthermore, fluoroscopy can be used to confirm the reduction and stability with stress. The wound is irrigated, the incision is closed and a splint is applied.
Common complications of the procedure include infection and damage to surrounding neurovascular structures, including the rare complication of dorsalis pedis artery pseudoaneurysm. The most common sequela of a Lisfranc injury is posttraumatic arthritis, which can potentially cause the patient pain, an altered gait and limitation of activity.
- References:
- Cottom JM, et al. J Foot Ankle Surg. 2008;doi:10.1053/j.jfas.2008.01.004.
- Desmond EA, et al. Foot Ankle Int. 2006;doi:10.1177/107110070602700819.
- Panchbhavi VK, et al. J Bone Joint Surg Am. 2009;doi:10.2106/JBJS.H.00162.
- Williams JC, et al. J Orthop Trauma. 2010;doi:10.1097/BOT.0b013e3181dab088.
- For more information:
- Eric Giza, MD; Christopher D. Kreulen, MD, associate professor, Orthopaedic Surgery - Adult Foot and Ankle Surgery, Sports Medicine; and Gregory T. Walker Jr., MD, an orthopedic fellow, can be reached at University of California – Davis, Department of Orthopaedic Surgery, 3301 C St., Suite 1700, Sacramento, CA 95816. Giza’s email: ericgiza@gmail.com. Kreulen’s email: ckreulen@gmail.com. Walker’s email: gregory.walker39@gmail.com.
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