SLR - March 2022 - Nehal Modha
Reference: Sethuraman, SA., Silverstein, RS., Dedhia, N., Shaner AC., Aspirino DE. Radiographic Outcomes of Cortical Screw Fixation as an Alternative to Kirschner Wire for Temporary Lateral Column Stabilization in Displaced Lisfranc Joint Fracture-Dislocations: A Retrospective Cohort Analysis. BMC Musculoskelet Disord. 2022 Jan 17;23(1):54.Level of Evidence: Level III, Retrospective cohort study
Scientific Literature Review
Reviewed By: Nehal Modha, DPM
Residency Program: Westside Regional Medical Center – Plantation FL
Podiatric Relevance: Lisfranc injuries can range from purely ligamentous to multiplanar unstable midfoot fracture-dislocations which are routinely anatomically fixed to minimize long-term sequelae including post-traumatic arthritis, pes planus deformity, and chronic pain. The lateral column of the foot has the greatest amount of sagittal plane motion and can tolerate more incongruity than the medial and middle columns. The lateral column has historically been omitted from osseous fixation. If persistent lateral instability remains in tarsometatarsal joint injuries it is commonly treated with Kirschner-wire fixation to maintain alignment during healing and allow for the return of physiologic motion after removal. More unstable fracture patterns may not maintain adequate reduction with Kirschner-wire fixation; these can be treated with temporary cortical screw fixation with implant removal six to twelve weeks post-operatively. In this study, the authors evaluated the efficacy of temporary lateral column cortical screw fixation as an alternative to Kirschner-wire fixation for these injuries.
Methods: This study reviewed 45 patients from 2008-2018 at a Level I trauma center who underwent osseous fixation of Lisfranc fracture dislocations. No purely ligamentous Lisfranc injuries were included. All patients underwent medial and middle column fixation with 3.5 cortical screws and 31 underwent lateral column fixation with 3.5 millimeters cortical screws or Kirschner-wires. Patients with incomplete records and patients lost to follow up were not included, therefore 26 patients remained in the study. Electronic medical records were reviewed for demographic data, ambulatory status, patient-reported pain, and return to normal shoe wear. The primary outcome measure was radiographically stable lateral column healing before and after implant removal. Secondary outcomes included a pain-free foot after screw removal, ambulation without aids, and return to normal shoe wear.
Results: In this study twenty six patients remained eligible for analysis. Mean age for the patients was 41.0 ± 16.9 years. Seven (26.9 percent) patients had staged hardware removal with a mean 15.7 weeks to partial hardware removal and seventeen (65.4 percent) patients underwent one-stage hardware removal with a mean 14.5 weeks to hardware removal. Two (7.7 percent) patients retained their hardware in both medial and lateral columns. Mean follow-up was 88.2 ± 114 weeks for all patients. Twelve (46.2 percent) patients had lateral column disruption treated with Kirschner-wire fixation and thirteen (50.0 percent) were treated with screw fixation. There were no differences between groups with respect to radiographically stable fixation prior to hardware removal, need for hardware removal, staged hardware removal, development of post-traumatic arthritis, and days between surgery and weight-bearing as tolerated. The cortical screw cohort had significantly longer mean time to hardware removal (p = 0.002). The Kirschner-wire cohort had significantly more disuse osteopenia (p = 0.045) and postoperative pain (p = 0.019).
Conclusions: This study demonstrated that temporary lateral column cortical screw fixation is a viable alternative in unstable Lisfranc joint injuries; using cortical screws provides equivalent radiographic outcomes to the current standard of care of Kirschner-wire fixation, and does not delay return to weight-bearing, unaided mobility or a return to normal shoe wear, while showing a greater reduction in postoperative pain.