SLR - March 2022 - Steven L. Anderson
Reference: Chen P, Ng N, Snowden G, Mackenzie SP, Nicholson JA, Amin AK. Percutaneous Reduction and Fixation of Low Energy Lisfranc Injuries Results in Better Outcome Compared to Open Reduction and Internal Fixation: Results from a Matched Case-Control Study with Minimum 12 Months Follow Up. Injury. 2021 Apr;52(4):1042-1047.Level of Evidence: III
Scientific Literature Review
Reviewed By: Steven L. Anderson, DPM
Residency Program: Grant Medical Center – Columbus, OH
Podiatric Relevance: Low energy Lisfranc injuries can be subtle, but restoration of normal joint congruity is essential for proper healing and prevention of midfoot arthritis. Reduction via direct visualization requires significant dissection and is associated with higher rates of soft tissue complications. Percutaneous techniques attempt to deliver comparable reduction without the soft tissue compromise seen with open reduction and internal fixation (ORIF). This study directly compared the clinical outcomes between percutaneous and open techniques for low energy Lisfranc injury.
Methods: Sixteen consecutive patients with Myerson B2-type Lisfranc injuries were treated with percutaneous reduction and internal fixation (PRIF). The technique involved placing a reduction clamp between the dorsolateral base of the second metatarsal and the medial cuneiform. Reduction was scrutinized under fluoroscopy and fixation was achieved with a 4.0 millimeters partially threaded cannulated screw, inserted from lateral to medial. This was compared to a matched control group of 16 patients with similar Myerson B2-type Lisfranc injuries treated with ORIF. The open technique involved reduction via direct visualization and screw only fixation with the Lisfranc screw inserted from medial to lateral. Clinical outcomes were compared using the American Orthopedic Foot and Ankle Society (AOFAS) midfoot score and the Manchester Oxford Foot Questionnaire (MOXFQ).
Results: The mean AOFAS and MOXFQ scores for the PRIF group were 89.1 and 10.1 respectively. None of the patients in the PRIF group developed post-traumatic osteoarthritis. Seven patients in the PRIF group (44 percent) underwent hardware removal. The mean AOFAS and MOXFQ scores for the ORIF group were 76.4 and 27.6 respectively. Three patients in the ORIF group (19 percent) developed midfoot osteoarthritis and one patient required a fusion. Nine patients in the ORIF group (56 percent) underwent hardware removal. There were no recorded post-operative complications for either group. All patients had a minimum radiographic follow up of one year.
Conclusions: While acknowledging the small sample size, the authors concluded that their percutaneous technique leads to better clinical outcomes compared to standard open technique. They lent at least part of their success to the lateral to medial orientation of their lag screw which gives the surgeon a larger target in the medial cuneiform compared to the second metatarsal base. This orientation also has the following benefits: direct reduction of dorsolateral displacement, greater capacity for thread length in the medial cuneiform, and more reliable passage through extra-articular bone. An inherent difficulty with the percutaneous approach is blind reduction. The authors stressed the effect of anatomic reduction on clinical outcomes and used all three radiographic views plus continuous fluoroscopy to insure proper reduction. If malreduction persists the surgeon can simply extend the incision and proceed with open reduction. None of the patients in this study required conversion to open reduction, but they had a relatively simple injury pattern. It stands to reason that more complex injury patterns would be less amenable to percutaneous reduction. As with any surgical procedure, the injury pattern and the experience of the surgeon should inform the surgical approach but for these low energy Lisfranc injuries PRIF is an excellent option with good results.