SLR - February 2020 - Stephanie N. Campbell

Flexible Fixation for Ligamentous Lisfranc Injuries

Reference: Briceno J, Stupay KL, Moura B, Velasco B, Kwon JY. Flexible Fixation for Ligamentous Lisfranc Injuries. Injury. 2019 Nov:50(11):2123-2127.

Scientific Literature Review

Reviewed By: Stephanie N. Campbell, DPM
Residency Program: West Penn Hospital – Pittsburgh, PA

Podiatric Relevance: Lisfranc injuries can vary from simple to complex with ligamentous and osseous injury. The level of injury can be quite variable. The injury requires stabilization of the tarsometatarsal and intercuneiform joints. This technical paper describes ligamentous repair for subtle lisfranc injury using flexible fixation with screws, washer and tensioned non-absorbable FiberWire as a possible construct. This article is of relevance due to the ongoing literature arguing for and against open reduction internal fixation verses primary arthrodesis of Lisfranc injury presenting a novel alternative therapy treatment. This article serves to understand that if anatomic joint alignment is maintained with balanced flexible internal fixation, that complications associated with the aforementioned surgical techniques may improve outcomes by avoiding joint stiffness, compensatory arthrosis, chronic pain, higher complication rates and cost of implant.

Methods: A dorso-medial approach is performed with subsequent abduction stress testing to determine the level of instability and need for flexible fixation. Two 2.7 or 3.5 screws with washers are placed along the base of the metatarsal and cuneiform acting as posts with figure of eight FiberWire suture fashioned around the screws and beneath the washers. The FiberWire is tensioned and secured with final tightening of the screws. The construct functions to increase resistance to dorso-plantar motion. Patients remain non-weightbearing for six weeks post operatively followed by four weeks protected weightbearing in fracture boot.

Results: Flexible fixation maintains anatomic reduction, allows for physiologic joint motion, and resumption of activity. Two of 12 patients required hardware removal at 14 month follow up, one due to soft tissue irritation and the second from loss of reduction at the second tarsometatarsal joint and was converted to arthrodesis.

Conclusions: There are varying levels of instability associated with lisfranc injury, requiring a spectrum of surgical treatment modalities. This paper argues that for subtle tarsometatarsal instability, as demonstrated by abduction stress testing with medial joint gapping under image intensification, flexible fixation can be performed and may be an advantageous fixation construct for ligamentous instability. The author’s support this fixation method as it is joint-sparing, maintains anatomic reduction of the Lisfranc complex, whilst allowing variable mobility to share load transfer in load bearing and ambulation, and more often eliminates the need for implant removal as compared to traditional ORIF with metal implants or suture buttons. For these reasons, it may also serve to be cost saving when considering total cost of care. Indications may be expanded beyond flexible fixation of Lisfranc ligament, including the lisfranc complex of tarsometatarsal joints one, two and three, intermetatarsal and intercuneiform joints. Minor avulsion fractures and minimally displaced fractures may be of consideration for this technique.  This technique should not be used for severe fracture dislocations, patients with whom strict non-weightbearing is a concern, or neuropathic patients. 

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