SLR - October 2013 - Sonia Mvuemba

Early Weight-bearing After Percutaneous Reduction and Screw Fixation for Low-energy Lisfranc Injury

Reference: Wagner, E., Ortiz, C., Villalón, I.E., Keller, A., &Wagner, P. (2013). Early Weight-bearing After Percutaneous Reduction and Screw Fixation for Low-energy Lisfranc Injury. Foot & Ankle International 34(7) 978-983.

Scientific Literature Review

Reviewed by: Sonia Mvuemba, DPM
Residency Program:
University Hospital, Newark, NJ

Podiatric Relevance: Fracture dislocation of the tarsometatarsal joint complex, also known as Lisfranc injury, occurs in 1 out of 55,000 people each year in the United States and accounts for about 0.2 percent of all fractures. Such injuries can be the result of either high energy trauma or low energy trauma. A high index of suspicion is required to diagnose this type of injury since 20 percent of these injuries are either misdiagnosed or missed upon initial radiographic evaluation. The goal of surgical treatment includes anatomic reduction with stable fixation. However, controversy exists on how this should be achieved, with some school of thoughts advocating the use of open reduction with internal fixation, while others advocate percutaneous reduction with screw fixation. Post traumatic arthritis can occur in up to 50 percent of cases even in the setting of adequate reduction and post-operative therapy. This study was performed to showcase the results of percutaneous reduction with screw fixation and early weight bearing in patient who sustained low energy type Lisfranc injuries.

Methods: A retrospective study of a consecutive series of patients who sustained low-energy Lisfranc fracture dislocation between May 2007 and April 2011 was performed. There were a total of 22 patients with an average follow-up period of 33.2 months. Patients with ligamentous lesions and with marginal fractures were included, while those with comminution at the bases of the metatarsals were excluded. The diagnosis was based on clinical evaluation and weight-bearing radiographs, with computed tomography used for evaluation only when the patient was unable to bear weight. Surgery was performed when there was more than 2 mm of diastasis between the bases of the first and second metatarsals and more than 1 mm of subluxation of the base of any given metatarsal from its corresponding tarsal. Following surgery, anatomic or near anatomic reduction was described as reduction within the previously stated limits. Every single patient was operated on percutaneously using 3.0 Synthes cannulated screws and all surgeries were performed by the same surgeon under fluoroscopy. Following surgery, patients remained non-weight bearing for three weeks, which was followed by weight bearing as tolerated in a controlled ankle movement walker boot or a stiff soled shoe. Transition to a regular shoe occurred six weeks post-surgery. Each patient was evaluated both clinically and radiographically at two weeks, six weeks, three months and one year post surgery. Outcomes were measured using post-operative radiographs as well as subjective satisfaction, AOFAS score and time required to return to activity.

Results: Radiographs of all patients showed anatomic or near-anatomic reduction. Nearly 91 percent of all patients (20 out of 22 patients) reported total satisfaction with an average AOFAS score of 94 points. The remaining two patients achieved total satisfaction following screw removal. Full weight bearing status was achieved between three and six weeks post-surgery. The average time to return to work was seven weeks, while the average time to return to recreational activity, low-impact sports, and sports activities symptom free was 7.2, 7.6, and 12.4 weeks, respectively. Complications ranged from hardware-related symptoms (reported by three patients) and transient paresthesia (reported by a single patient).

Conclusions: Although anatomic reduction with use of stable internal fixation has become the standard for the treatment of Lisfranc injury among foot and ankle surgeons, percutaneous reduction with screw fixation under fluoroscopy represents a reasonable alternative, especially in patients who sustained low-energy type of injury given that it can potentially cause less soft tissue trauma and allows and can allow for a quick recovery with fewer complications.

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