SLR - September 2017 - Aniela Cordoba
Functional Outcomes Post Lisfranc Injury: Transarticular Screws, Dorsal Bridge Plating or Combination Treatment?
Reference: Lau S, Guest C, Hall M, Tacey M, Joseph S, Oppy A. Functional Outcomes Post Lisfranc Injury: Transarticular Screws, Dorsal Bridge Plating or Combination Treatment? J Orthop Trauma. 2017 Aug;31(8):477–452
Scientific Literature Review
Reviewed By: Aniela Cordoba, DPM
Residency Program: North Colorado Medical Center, Greeley, CO
Podiatric Relevance: Lisfranc fracture dislocations are some of the more disabling injuries of the foot and ankle. These injuries require prompt surgical intervention when identified. There is plenty of controversy regarding these injuries, from how often they are missed to surgical approach. It is imperative for podiatric surgeons to keep up with the literature regarding Lisfranc injuries to offer patients the best functional outcomes. Best evidence to date advocates for anatomical reduction of less than 2 mm, but there is still a question of technique. This article offers some insight into the surgical approach by retrospectively comparing three methods for an average follow-up of 4.8 years.
Methods: This was a retrospective study of 50 patients with 50 Lisfranc injuries at a level one trauma center via a coding data search. Included patients had open or closed fractures or dislocations of TMTJ with minimum follow-up of two years. Each case was divided into one of three groups: fixation by transarticular screws; fixation by dorsal bridge plate alone; and combination of transarticular screw with dorsal bridge plate. Variability of technique was based on the surgeon’s preference at the time. Neutralization plates used were either 2.4 or 2.7 variable angle midfoot plates, and screws were 2.7 or 3.5 mm cortical. All patients were immobilized for six weeks followed by six weeks of protected weightbearing with CAM boot. Functional outcomes were measured using Foot Function Index and AOFAS midfoot score.
Results: Mean follow-up was 4.81 years (range 2.08–8.27). There were 34 men and 16 women with half of injuries stemming from motor vehicle accidents. Most common fracture type was Myerson B2 (52 percent.) Ninety percent of injuries were closed. Fourteen were fixed by transarticular screws alone; 19 were fixed by plating; and 17 were combination. No statistically significant difference was found between the three treatment groups in terms of both FFI or AOFAS scoring (P = 0.65.) Postoperative reduction radiographs were graded based on Wilppula score of good, fair or poor.
There were 13 good reductions; 28 fair; and 9 poor reductions. Fifteen of the combination patients required hardware removal at a mean of 391 days; seven plates removed at 241.8 days; and five screws removed at 165.5 days. Complications included six superficial infections (five combo or plate approach), one broken transarticular screw (part of combo approach) and one combination approach nonunion.
Conclusions: This was a single center, retrospective and overall weak study with a small sample size. The authors claim that this is one of the larger studies in terms of sample size to date. They used two outcome scores that have not been validated, and patient satisfaction was not discussed. There was no clear algorithm on how the surgical approach was decided as there is no validated classification system for Lisfranc fracture dislocations. Despite these limitations, there was no correlation between ORIF approach and functional outcome. The goal of Lisfranc surgery should be accurate reduction no matter the approach.