Severe Lisfrancs injuries: primary arthrodesis or ORIF?

Twenty-eight patients, with severe, acute Lisfranc dislocations, requiring operative intervention, were treated between 1989 and 1992 in a level one Trauma Center. Different treatment protocols were used by the two senior staff surgeons. This allowed ORIF to be compared to complete arthrodesis and partial arthrodesis. Twelve patients were treated with primary arthrodesis after open reduction of the dislocation. Partial (5) or complete arthrodesis (6) (depending on the type of fracture) was performed in these 12 patients. Sixteen patients were treated with open reduction and temporary fixation with stabilization and compression screw fixation (ORIF group). The subgroups were identical in age (mean 30.5 years), follow-up (30.1 months), type of fracture, type of injury and time to intervention. Anatomical reduction was achieved in eight of the 12 patients in the arthrodesis groups and in 12 of the 16 patients in the ORIF group. The Baltimore Painful foot Score (PFS) was higher in the ORIF group then in the complete arthrodesis group meaning the ORIF group had less pain. No difference in the PFS was found between the ORIF group and the partial arthrodesis group. Subsequent revision surgery was necessary in two cases in the arthrodesis groups and two cases in the ORIF group. Stiffness of the forefoot, loss of metatarsal arch, and sympathetic dystrophy occurred more frequently in the complete arthrodesis group. Open reduction and internal fixation with screws or partial arthrodesis is the treatment of choice in severe tarsometatarsal fracture dislocations. Primary complete arthrodesis should be reserved as a salvage procedure.     

Lisfranc损伤一期切复内固定与延期融合治疗的比较

目的：比较Lisfranc损伤的一期切开复位内固定与二期矫形关节融合的疗效。方法：对27例Lisfranc关节损伤患者行一期切复克氏针、螺钉或钢板内固定,对23例患者行二期畸形矫正关节融合术。按照Maryland足部评分及AOFAS中足评分标准进行疗效评定。结果：AOFAS评分一期切复内固定组平均84.9,二期融合组平均71.5。Maryland评分一期切复内固定组平均87.2,二期矫形关节融合组平均72.3。一期切复内固定组术后5.1个月（3～12个月）恢复正常生活,二期矫形关节融合组术后6.3个月（4～16个月）恢复正常生活,切复内固定组6例并发骨关节炎,融合组出现1例延迟融合。结论：Lisfranc骨折脱位一期切开复位内固定治疗,功能改善更明显,患者满意度较高。二期融合也能明显缓解疼痛,改善功能。     

不同方法治疗跖跗关节损伤疗效分析

目的探讨不同方法治疗跖跗关节损伤的临床疗效。方法分别采用石膏固定、闭合复位经皮内固定、开放复位内固定和二期关节融合术治疗35例跖附关节损伤患者。结果患者均获随访,时间12～36(22±1.5)周,骨折愈合时间16～28(18±2)周。术后12周33例患者能穿平常鞋子在各种地面上行走,步态基本正常。按AOFAS评分:优11例,良18例,可5例,差1例。结论解剖复位、牢靠固定是治疗跖跗关节损伤的基本原则。重建跖跗关节复合体是稳定的关键,并且需要重视对跖跗关节的整体化治疗。     

跖跗关节复合体损伤的手术治疗

目的 评价跖跗关节复合体损伤的手术治疗效果.方法 2003年1月至2008年12月,共收治167例闭合性跖跗关节损伤患者,其中跖跗关节复合体损伤35例.通过X线及CT检查明确诊断,闭合或切开复位螺钉或钢板内固定,术后定期放射学检查随访,以美国足踝外科协会(AOFAS)中足评分系统进行功能评估.结果 本组有135例获得12～78个月随访,平均随访时间48个月.其中跖跗关节复合体损伤26例,术后AOFAS评分48～75分,平均67分;其中16例继发创伤性关节炎,12例因疼痛明显、行走受限二期行关节融合术;单纯跖跗关节损伤109例,术后AOFAS评分70～95分,平均82分,继发创伤性关节炎的17例中5例二期行关节融合术.单纯跖跗关节损伤闭合复位经皮螺钉内固定者术后AOFAS中足评分82～95分,平均87分,与跖跗关节复合体损伤者比较差异具有统计学意义(t=2.651,P<0.05).结论 跖跗关节复合体损伤的预后比单纯跖跗关节损伤的差,而准确诊断、实现复合体各个部分的解剖复位和可靠固定是取得良好治疗效果的关键.     

Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study

BACKGROUND: Open reduction and internal fixation is currently the accepted treatment for displaced Lisfranc joint injuries. However, even with anatomic reduction and stable internal fixation, treatment of these injuries does not have uniformly excellent outcomes. The objective of this study was to compare primary arthrodesis with open reduction and internal fixation for the treatment of primarily ligamentous Lisfranc joint injuries. METHODS: Forty-one patients with an isolated acute or subacute primarily ligamentous Lisfranc joint injury were enrolled in a prospective, randomized clinical trial comparing primary arthrodesis with traditional open reduction and internal fixation. The patients were followed for an average of 42.5 months. Evaluation was performed with clinical examination, radiography, the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale, a visual analog pain scale, and a clinical questionnaire. RESULTS: Twenty patients were treated with open reduction and screw fixation, and twenty-one patients were treated with primary arthrodesis of the medial two or three rays. Anatomic initial reduction was obtained in eighteen of the twenty patients in the open-reduction group and twenty of the twenty-one in the arthrodesis group. At two years postoperatively, the mean AOFAS Midfoot score was 68.6 points in the open-reduction group and 88 points in the arthrodesis group (p < 0.005). Five patients in the open-reduction group had persistent pain with the development of deformity or osteoarthrosis, and they were eventually treated with arthrodesis. The patients who had been treated with a primary arthrodesis estimated that their postoperative level of activities was 92% of their preinjury level, whereas the open-reduction group estimated that their postoperative level was only 65% of their preoperative level (p < 0.005). CONCLUSIONS: A primary stable arthrodesis of the medial two or three rays appears to have a better short and medium-term outcome than open reduction and internal fixation of ligamentous Lisfranc joint injuries.     

Combined Medial Column Primary Arthrodesis,Middle Column Open Reduction Internal Fixation,and Lateral Column Pinning for Treatment of Lisfranc Fracture-Dislocation Injuries

Lisfranc fracture-dislocation can be a devastating injury with significant long-term sequelae, including degenerative joint disease, progressive arch collapse, and chronic pain that can be potentiated if not effectively treated. We present a case to demonstrate our preferred surgical approach, consisting of combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning, with the primary goal of minimizing common long-term complications associated with Lisfranc injuries. We present the case of a typical patient treated according to this combined surgical approach to highlight our patient selection criteria, rationale, surgical technique, and operative pearls. A 36-year-old male who had sustained a homolateral Lisfranc fracture-dislocation injury after falling from a height initially underwent fasciotomy for foot compartment syndrome. The subsequent repair 16 days later involved primary first tarsometatarsal joint fusion, open reduction internal fixation of the second and third tarsometatarsal joints, and temporary pinning of the fourth and fifth tarsometatarsal joints. He progressed well postoperatively, exhibiting an American College of Foot and Ankle Surgeons forefoot score of 90 of 100 at 1 year after surgery with no need for subsequent treatment. Lisfranc fracture-dislocations often exhibit primary dislocation to the medial column and are conducive to arthrodesis to stabilize the tarsometatarsal complex. The middle column frequently involves comminuted intra-articular fractures and will often benefit from less dissection required for open reduction internal fixation instead of primary fusion. We propose that this surgical approach is a viable alternative technique for primary treatment of Lisfranc fracture-dislocation injuries.     

陈旧性Lisfranc损伤的成因与治疗

目的 分析陈旧性Lisfranc损伤的形成原因,探讨其手术治疗方法及效果. 方法2004年8月至2008年6月共收治20例陈旧性Lisfranc损伤患者,男16例,女4例;年龄21～49岁.术前均行CT三维重建,按照Myerson分型:Ⅰ型3例,Ⅱ型13例,Ⅲ型4例.17例患者行切开复位内固定,采用克氏针或螺钉固定,3例行关节融合术.术后按照Maryland足功能评分标准进行疗效评定. 结果 18例患者术后获6个月～4年(平均27个月)随访,2例失访.18例患者术后无内固定断裂、再骨折脱位等并发症发生.按照Maryland足功能评分标准评定疗效:66～96分,平均85分;其中优3例,良12例,可3例,优良率为83.3%.疗效欠佳的主要表现为中足疼痛、活动度减少. 结论影像学表现不典型、治疗不及时、方法选择有误等均可能造成陈旧性Lisfranc损伤.解剖复位、牢固内固定、重建足弓、恢复维持足部内外侧纵弓及横弓解剖形态是治疗的关键.     

Subtle injuries of the Lisfranc joint

In fifteen patients, a subtle injury of the Lisfranc joint (tarsometatarsal articulation) was found. The lesion was defined as a diastasis of two to five millimeters between the bases of the first and second metatarsals, as seen on anteroposterior radiographs. There often was a long delay between injury and diagnosis. Eight patients were treated with a below-the-knee cast only, three had treatment with a cast and then tarsometatarsal arthrodesis, two had no initial treatment but later had arthrodesis, and two had open reduction and internal fixation. The duration of follow-up ranged from two to thirteen years after the diagnosis. There was no correlation between the severity of the diastasis and the patient's functional result. Marked disability and pain persisted in seven patients, and six of them had flattening of the longitudinal arch. Maintenance of the longitudinal arch usually was associated with a better functional outcome. When a patient has a subtle injury of the Lisfranc joint, weight-bearing lateral radiographs of both feet are needed to identify flattening of the longitudinal arch. Such radiographs should be made routinely in the evaluation of all injuries of the foot that may involve the Lisfranc joint.     

Treatment of chronic perilunate dislocations

Fifteen patients with 16 perilunate dislocations that had been untreated for a minimum of 6 weeks after the injury were evaluated after subsequent treatment at a mean of 6.4 years. The median time from injury to definitive treatment was 17 weeks. Ten wrists had completely ligamentous injuries and six had fracture-dislocations. Treatment consisted of open reduction and internal fixation in six patients, isolated carpal bone excision in four, wrist arthrodesis in two, proximal row carpectomy in two, and bilateral carpal tunnel release in one. In this series the results of excision of the lunate or scaphoid alone were uniformly poor. One of the two patients who had a proximal row carpectomy required secondary radial styloidectomy, and a pseudarthrosis developed in one of the two patients who had a wrist arthrodesis. All six patients treated by open reduction and internal fixation had satisfactory outcomes and none required additional surgery.     

Primary subtalar arthrodesis for the treatment of comminuted intra-articular calcaneal fractures

We report the short- and mid-term results in six patients (seven feet) affected by markedly comminuted intra-articular calcaneal fractures (Sanders type IV), treated by primary subtalar arthrodesis. The average age at surgery was 40 years. In all patients, arthrodesis of the subtalar joint was performed using a limited lateral approach to the calcaneus; it was stabilised with two or three cannulated screws. No patient had a preliminary reduction and internal fixation of the fracture. The time from injury to surgery averaged 20 days because all of the patients had associated visceral and/or other skeletal injuries. All of the patients were followed up clinically and radiographically 2 times, at an average of 12 months and 53 months after surgery. At the short-term follow-up, the mean AOFAS score was 70 points; the X-rays showed a complete fusion of the subtalar joint in all seven feet, without any sign of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints. In all cases, an altered shape of the calcaneus was present. At the mid-term follow-up, the mean AOFAS score increased to 85 points; in one patient, radiographic signs of osteoarthritis of the calcaneo-cuboid and the talo-navicular joints were present and, in another patient, only talo-navicular joint was present, although both patients were free from pain. The difference between the two AOFAS scores was statistically significant. We believe that primary subtalar arthrodesis performed for markedly comminuted Sanders type IV calcaneal fractures yielded good mid-term results, and it is especially indicated when surgical treatment is delayed for whatever reason. A preliminary open reduction and internal fixation to restore the normal height of the calcaneus before performing the subtalar arthrodesis, as suggested by several authors, does not seem indispensable to obtain good clinical results.     

早期清创复位克氏针内固定与Ⅱ期钢板内固定治疗开放性跟骨骨折的病例对照研究

目的:比较早期清创骨折复位克氏针内固定(克氏针组)与Ⅱ期骨折复位钢板内固定(钢板组)治疗开放性跟骨骨折的临床疗效。方法:自2001年1月至2008年5月收治开放性跟骨骨折55例(58足),年龄19～65岁,平均36.8岁;伤后至就诊时间30min～7h,平均3h。克氏针组:男20例(20足),女9例(9足);软组织损伤Gustilo分型,Ⅰ型15足,Ⅱ型13足,ⅢA型1足;跟骨骨折Sanders分型,Ⅱ型9足,Ⅲ型18足,Ⅳ型2足;采用早期清创骨折复位克氏针固定治疗,软组织缺损采用VSD临时覆盖,Ⅱ期皮片或皮瓣移植术。钢板组:男18例(19足),女8例(10足);软组织损伤Gustilo分型,Ⅰ型13足,Ⅱ型14足,ⅢA型2足;跟骨骨折Sanders分型,Ⅱ型11足,Ⅲ型15足,Ⅳ型3足;采用早期清创,创面稳定后采用Ⅱ期骨折复位钢板内固定治疗。通过临床检查、影像学评估和AOFAS踝与后足评分进行预后评估。结果:克氏针组15例(23足)和钢板组13例(22足)得到随访,随访时间10～36个月,平均24个月。2组患者最后一次随访时的X线片与术前比较,跟骨高度、宽度、B觟hler角和Gissane角均有改善。根据AOFAS踝-后足评价,克氏针组优11足,良8足,可3足,差1足,术后早期伤口局部皮肤坏死2足,经换药后治愈,1足出现大面积皮肤坏死并深部感染,1足出现慢性骨髓炎,后期均行关节融合术;钢板组优7足,良4足,可4足,差7足,清创早期轻度并发症2例,慢性骨髓炎1例,Ⅱ期术后切口并发症10例,其中皮肤坏死7例,浅表感染3例。2组放射学指标和AOFAS踝-后足评分比较,差异有统计学意义;而清创术后早期并发症比较,差异无统计学意义。结论:早期清创克氏针固定治疗开放性跟骨骨折早期并发症较少,是一种简单安全有效的治疗方法。     

Die Lisfranc-Arthrodese nach Fehlheilung

The causes of residual deformity with posttraumatic painful arthritis after tarsometatarsal (Lisfranc) fracture-dislocation with the need for correctional arthrodesis are in our experience (22 cases over 5 years) overseen injuries in one third, closed reduction and immobilisation or inadequate fixation technique with K-wires in another two thirds of cases. Foot malalignment and residual instability is assessed with weight-bearing radiographs of both feet, adduction/abduction stress films and CT scans for complex deformity. Correction is carried out via two longitudinal dorsal incisions, strict epiperiosteal preparation and debridement of the Lisfranc joint of all remaining cartilage, sclerosis and fibrous tissue. Reorientation begins, in the same manner as primary open reduction, with anatomical alignment of the second metatarsal base to the second cuneiform. Defects are filled with autologous bone grafting, stable fusion can be achieved with 3.5 mm cancellous compression screws. Full weight bearing is allowed in a modelled plaster shoe for 6 to 8 weeks. The functional medium-term results are convincing with 15 of 17 patients seen after 13 months of follow-up working full time. The Maryland Foot Score improved from 38.9 to 76.8 points in these patients.     

跖跗关节复合体损伤的诊治探讨

目的：探讨跖跗关节复合体（TJC）损伤的诊治方法。方法：2007年1月至2009年12月采用切开复位内固定治疗16例跖跗关节复合体损伤,男12例,女4例;年龄21～45岁,平均34.1岁,均为闭合性损伤。左侧7例,右侧9例,均为直接暴力所伤,其中交通伤4例,高处坠落伤5例,挤压伤7例。楔骨间脱位11例,舟楔关节脱位3例,骰骨骨折2例。跖跗关节损伤均为三柱损伤。根据手术探查和稳定性破坏情况,通常跗骨间关节,内侧、中间柱跖跗关节用螺钉固定,外侧柱用克氏针固定,对跖骨基底部粉碎性骨折和骰骨压缩性骨折等用跨关节微型钢板固定以达到解剖复位、有效固定。采用美国足踝外科协会（AOFAS）中足评分标准从疼痛、功能、对线方面进行临床评估。结果：所有患者均获得随访,时间6～18个月,平均12.6个月。按AOFAS评分：疼痛为（29.3±5.9）分,功能为（32.4±5.6）分,对线为（12.9±2.6）分,总分为（74.6±10.4）分。所有切口均Ⅰ期愈合,未见皮肤坏死,感染,钢板螺钉松动、断裂等并发症。3例患者因后期出现骨性关节炎,疼痛明显,行走困难,Ⅱ期行关节融合术。4例患者影像学表现为骨性关节炎,但临床症状（疼痛）较轻,继续观察随访。结论：解剖复位有效稳定内固定是治疗跖跗关节复合体损伤的关键要素,Ⅰ期切开复位内固定有利于Ⅱ期融合手术。     

Treatment of the missed Lisfranc injury

Lisfranc joint injuries may be missed at the time of occurrence potentially leading to persistent instability, deformity, or arthritis. In the absence of significant residual arthritis or fixed deformity, delayed open reduction and internal fixation with or without reconstruction of the Lisfranc ligament may be performed. An alternative is reduction and primary arthrodesis of the relatively immobile medial tarsometatarsal (TMT) joints. In the presence of significant residual arthritis or fixed deformity that is recalcitrant to conservative treatment, arthrodesis, including correction of deformity, is the treatment of choice for the first, second, and third TMT joints. Resection arthroplasty of the fourth and fifth TMT joints may be preferable to arthrodesis in order to maintain physiologic motion.     

Progression of Healing on Serial Radiographs Following First Ray Arthrodesis in the Foot Using a Biplanar Plating Technique Without Compression

A review of 195 first ray arthrodeses fixated with a twin-plate biplanar construct, without interfragmentary compression, is presented. This fixation construct was evaluated in a consecutive cohort of patients undergoing first metatarsophalangeal joint (MTP) arthrodesis or the first tarsometatarsal joint (TMT) arthrodesis. Multiple radiographs were used to assess the progression of healing at the following postoperative time frames: 4 to 9 weeks, 10 to 12 weeks, >12 weeks, and the final follow-up. In total, 85 feet underwent first MTP arthrodesis, and 110 feet underwent first TMT arthrodesis. At the final radiographic follow-up, 97.44% of all cases had shown progressive osseous gap filling at the arthrodesis site, stable position of the bone segments, and intact hardware without loosening, 98.24% of the first MTP arthrodesis group and 96.82% of the first TMT arthrodesis group. Five (5.43%) feet had the presence of lucency at the fusion interface at the final follow-up, without positional change or hardware failure. Four (1.8%) feet had a failure of the hardware, loss of position, or frank gapping at the fusion site. Lucency decreased consistently over time in this series of patients (p < .00001). Progressive increase in callus density at the fusion site on serial radiographs was noted to be a consistent finding for both procedures and was the primary indicator of secondary bone healing at the noncompressed, relatively stable arthrodesis site. Our results confirm that biplanar plating construct without interfragmentary compression produces high fusion rates following the first MTP or TMT arthrodesis, with early weightbearing.     

Management of compartment syndromes of the foot.

Twelve patients with isolated extremity injuries had 14 compartment syndromes of the feet. An interstitial pressure of more than 30 mm of mercury in either the central or interosseous compartment was considered pathologic and was treated by fasciotomy, performed dorsally in nine feet and medially in five. Open reduction of fractures amenable to internal fixation (eight tarsometatarsal, three calcaneus, and one metatarsal) was performed after completion of the fasciotomies. The fasciotomy wounds were covered by primary split-thickness skin excision (three), delayed split-thickness skin grafting (eight), and delayed primary wound closure (three). Patients were evaluated at a mean of 22 months (range, 17-36 months) after injury, and the examination was directed specifically toward symptoms and signs of myoneural ischemia. Absolute compartment pressure measurements are more accurate than clinical findings in the diagnosis of a compartment syndrome of the foot. Fasciotomy may be performed medially or dorsally, depending on the configuration of the pattern of fracture or dislocation. To ensure satisfactory results, all compartments should be decompressed, and the pressures remeasured after the completion of fasciotomy.     

First metatarsophalangeal joint arthrodesis as a treatment for failed hallux valgus surgery

BACKGROUND: The results of first metatarsophalangeal (MTP) joint arthrodesis as a specific treatment for failed hallux valgus correction has not been previously reported. We evaluated the results of first metatarsophalangeal (MTP) joint arthrodesis as a treatment for failed hallux valgus surgery. METHODS: The records of the senior author (MJC) were reviewed to identify patients treated for symptomatic failed hallux valgus procedures with arthrodesis of the first metatarsophalangeal joint over a 20-year period. Twenty-nine patients (33 feet) were available for followup examination. The patients completed a visual analog pain score, the American Orthopaedic Foot and Ankle Society (AOFAS) Hallux Metatarsophalangeal-Interphalangeal Scale, and a patient satisfaction scale at the final followup. Radiographs were obtained of both feet. RESULTS: The average followup was 8 (1 to 22) years. The average pain score improved from 7 to 3 points. The mean AOFAS score was 73 points at followup. Patient satisfaction was excellent for 13 feet (39%), good in 11 (33%), fair in eight (24%), and poor in one (3%). The mean hallux valgus angle was 16 degrees, with an intermetatarsal angle of 8 degrees. There were three asymptomatic and one symptomatic nonunions. Twenty-two feet (67%) had corrective procedures performed on the lesser toes at the time of the first MTP joint arthrodesis. CONCLUSIONS: First MTP joint arthrodesis is a reliable option for revision after failure of surgical treatment of hallux valgus. This procedure can be used to treat a number of failure modes following initial hallux valgus surgery including recurrence, hallux varus, cock-up deformity, degenerative arthritis of the MTP joint, and associated transfer lesions beneath the lesser metatarsals. First MTP joint arthrodesis can be used after failed proximal and distal osteotomies, arthrodesis of the metatarsocuneiform joint, McBride procedure, exostectomy, and resection arthroplasty. Revision procedures have poorer clinical outcomes than successful primary hallux valgus procedures.     

High-energy bilateral talar neck fractures secondary to motocross injury.

The authors present a case of bilateral Hawkins type II talar neck fractures sustained during a motocross race in a 23 year old man. Due to the complexity of the injuries, open reduction with internal fixation and primary subtalar joint arthrodesis was performed bilaterally. This is one of the few cases of bilateral talar neck fractures reported in the literature in the past 15 years and one of the first utilizing open reduction and internal fixation with concomitant subtalar joint arthrodesis as a primary treatment.     

Arthrodesis in Acute and Chronic Lisfranc's Patients: A Retrospective Cohort Study

Injury to Lisfranc's joint complex affects the longitudinal and transverse arches of the foot and can significantly alter its biomechanics. Some of the previous studies have suggested primary arthrodesis to be superior to open reduction and internal fixation for treating primarily ligamentous Lisfranc injuries. Additionally, arthrodesis is often used for treating chronic Lisfranc injuries, including those which previously underwent open reduction and internal fixation and subsequently developed arthrosis. The purpose of this study was to retrospectively evaluate the outcomes of arthrodesis at the level of Lisfranc's articulation for both acute and chronic injuries. Patients who underwent midfoot arthrodesis surgical procedures between years 2001 and 2017 were retrospectively reviewed. About 187 patients with an average age of 55.9 ± 13.2 years old and a minimum follow-up of 1 year were included in the study. Median time to return to preoperative activities was 11 weeks. Overall successful joint fusion rate was 81.4%. However, concomitantly fused joints of the midfoot and hindfoot, in addition to the tarsometatarsal joints (TMTJ), were included in the overall fusion rate. Fusion rate at the first TMTJ was 90.2% (101 out of 112), second TMTJ was 94.4% (67 out of 71), and third TMTJ was 97.8% (45 out of 46). The present study demonstrates that patients who undergo arthrodesis for both acute and chronic Lisfranc injuries typically can return to activity in under approximately 3 months postoperatively (acute patients significantly faster) with a high union rate at the TMTJs. However, the overall union rate is significantly lower when concomitant proximal midfoot and rearfoot arthrodesis procedures are performed.