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ACTA ORTHOPAEDICA et TRAUMATOLOGICA TURCICA

www.aott.org.tr

Research Article

Staged surgical treatment of open Lisfranc fracture dislocations using an


adjustable bilateral external fixator: A retrospective review of 21 patients

Xi Liu1 , Jingjing An1 , Yu Chen2 , Wei Deng2 , Xuemei An3 , Hui Zhang1

1
Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
2
Department of Orthopaedic Surgery, Shangjin Nanfu Hospital, Chengdu, Sichuan Province, China
3
Department of Neurology, the Affiliated Hospital of Chengdu University of TCM, Chengdu, Sichuan Province, China

A R T I C L E I N F O ABSTRACT
Article history: Objective: The aim of this study was to assess the early operative results of a staged progressive reduction technique using a
Submitted 28 April 2019 bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations.
Received in revised form
17 February 2020 Methods: In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with
Last revision received open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean
17 May 2020 follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first
Accepted 12 July 2020 stage, a bilateral spanning external fixator was applied across the injured Lisfranc joint, and the length of the disrupted columns
was restored by distraction process. Vacuum-assisted closure was used if required. At the second stage, the external fixator was
Keywords: removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and
Lisfranc injury
postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and
Staged management
External fixation
the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic
Infection parameters indicating the alignment of the midfoot after the second operation were examined.
Anatomical reduction
Results: Deep infection in one patient and superficial infection in 2 patients were observed. Venous thrombosis was detected in
3 patients. The mean interval between the first and second stages was 18.6 days (range=8 to 48 days). The first metatarso-cunei-
ORCID iDs of the authors:
X.L. 0000-0002-5273-5645; form step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The
J.A. 0000-0002-8317-043X; mean VAS score was 2.4 (range=0-5), and the mean AOFAS score was 76.3 (range=63 to 97). Primary arthrodesis was performed
Y.C. 0000-0002-3184-3858; in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis.
W.D. 0000-0003-4409-2712;
Conclusion: With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external
X.A. 0000-0002-7911-0952;
H.Z. 0000-0001-5574-243X. fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislo-
cations in a short-time follow-up.

Level of Evidence: Level IV, Therapeutic study

Introduction worth debating. It is true that repeated manipulation


through the injured soft tissue envelope may cause
Though rare, Lisfranc fracture dislocations are severe secondary impairment if edema and inflammation are
injuries of the midfoot region (1). As proved by earlier present. Besides, the internal fixation underneath the
studies, the outcome of Lisfranc fracture dislocations injured soft tissue may increase the risk of deep infec-
is closely related to the extent of restoration and main- tion. This study on a series of consecutive cases aimed
tenance of anatomic alignment of each column (2-4). to report the early result of a staged and progressive
Open Lisfranc fracture dislocations are more difficult reduction technique using a bilateral external fixator to
to treat compared with those injuries with the skin and treat open Lisfranc fracture dislocations.
soft tissue remaining intact, mostly due to the vulnera-
bility of the affected soft tissue to accommodate reduc- Materials and Methods
tion maneuver and instrument placement to restore
and maintain the anatomic alignment, which leaves This study was approved by the Biomedical Research
little safe space for orthopedic surgeons to operate (5). Ethics Committee of West China Hospital of Sichuan
Corresponding Author:
Hui Zhang In order to achieve satisfactory outcome and to mini- University (file number: 1.0; file year: 2019). Clinical
zhanghuishangjin@163.com mize complication rates, various strategies have been data of patients with Lisfranc fracture dislocations, who
proposed to treat open Lisfranc fracture dislocations, were over 18 years of age and admitted to our trauma
such as primary internal fixation, soft tissue recon- center between January 2012 and December 2015, were
Content of this journal is struction, and staged management protocols. Although retrospectively reviewed by using the hospital informa-
licensed under a Creative these strategies are different, they all seek to accom- tion system. Patients who refused to participate, those
Commons Attribution-
plish immediate anatomic reduction once for all. Yet with incomplete required medical information on re-
NonCommercial 4.0
International License. the necessity of this attempt at the emergency stage is cord, those who died before definitive internal fixation

Cite this article as: Liu X, An J, Chen Y, Deng W, An X, Zhang H. Staged surgical treatment of open Lisfranc fracture dislocations using an adjustable bilateral external
fixator: A retrospective review of 21 patients. Acta Orthop Traumatol Turc 2020; 54(5): 488-96

488 DOI: 10.5152/j.aott.2020.19221


Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96

because of reasons other than the injury itself, and those who received a b
primary amputation for the injury were excluded from the study. All
the patients who participated in this study signed the consent form.

First-generation cephalosporin was routinely used for all of the pa-


tients, including the ones with grade III open fractures, as soon as
the patient arrived (6). In the case that the patient was allergic to
cephalosporin, clindamycin was prescribed instead. The antibiotics
being used would be changed according to the culture result once
there were signs of early infection. The wound of a typical case is
demonstrated in Figure 1. Preoperative anteroposterior (AP), lateral,
and oblique view radiographs and 3D CT reconstructive images were
obtained. The preoperative X-ray and CT reconstructive images of
the typical case are shown in Figure 2. Parecoxib was used before
surgery for preemptive analgesia if no contraindication was present.
Figure 1. a, b. A typical open Lisfranc injury in the current study. A 43-year-
All the operations were performed by the same senior orthopedic sur- old female patient got injured in a car accident. The pictures show the injury
geon (H.Z.), under general anesthesia, with the patients lying in the su- with contusion, laceration, and contamination of the right (a) planta pedis and
(b) dorsum pedis
pine position. All of the cases were managed in a staged fashion. At the
first stage, careful evaluation of the wound was performed according
was stabilized with a bilateral external fixator after the first-stage oper-
to the presence of tissue defect, the severity of contamination, and the
ation, are shown in Figure 3.
time from injury to the first debridement. Wounds that allowed safe
primary closure were closed, and others were sealed with vacuum-as- VAC system was used when there was skin and soft tissue defect or
sisted closure (VAC) systems (KCI, San Antonio, TX, USA). A span- if the wound could not be safely closed at primary intention. Wound
ning bilateral external fixator was applied across the injured Lisfranc debridement was performed approximately every 72 hours until
joint, with one transfixing pin placed through the calcaneal tuberosity the wound was ready for closure or repair. For the wounds without
and another one or two through the shaft of the metatarsals. For the sign of infection, the external fixator was then removed and the sec-
cases with disruptions of all three columns, the pins were positioned ond-stage treatment, which included open reduction and internal
through all the five metatarsals. For those patients with disruptions of fixation using transarticular cannulated screws for the medial and
only one or two columns, the pins were inserted through the disrupted middle columns and K-wires for the lateral column, was carried out
columns. Half pins were added to maintain the gross alignment and as described in our previous study using a dorsal approach overlying
the relative length of the impaired column if severe comminution and the involved column or columns (7). Furthermore, a simultaneous
instability of the lateral or medial column were present. The length wound closure or repair with skin graft or local tissue flap transfer
of the disrupted columns was restored by traction or sometimes over was performed. For those cases with severely comminuted columns,
traction, by distraction process of the external fixator. The alignment small unilateral external fixators were used instead. Anatomic reduc-
was reduced by clamping and joystick technique to a relatively normal tion was achieved at this stage. For patients with major ligamentous
state to reduce the skin compression or vascular tortuosity. Absolute disruptions and multidirectional instability of the Lisfranc joints, a
anatomic reduction was not obligatory at this time. For patients whose comminuted intraarticular fracture at the base of the first or second
reduction was satisfactory during the first-stage operation, the fracture metatarsus, or crush injuries of the midfoot with an intraarticular
or the dislocated tarsometatarsal (TMT) joint was further stabilized fracture dislocation, a primary arthrodesis of the involved first to
with Kirschner wires (K-wires) in addition to the external fixator. For third TMT joint or joints was performed (8). For heavily contaminat-
Gustilo type IIIC cases with vascular impairment and anastomosis, the ed wounds with a high risk of infection or wounds already showing
distraction process was slowly and progressively performed after the sign of infection, the external fixator was placed, and gentamicin ce-
operation with intensive monitoring of the acral blood supply to avoid ment beads were embedded. The wound was sealed with VAC sys-
irritation of the anastomotic vessels. The distraction was set back once tem with continuous instillation using 0.9% saline. Definitive reduc-
any sign of circular disturbance of the involved extremity was noticed. tion and internal fixation would not be performed until the infection
The X-ray images of the affected foot in a typical case, where the foot was under control. Figures 4 and 5 demonstrate the post-second-stage
operation X-ray images of a typical case with the comminuted lateral
column fixed with a small unilateral external fixator and K-wires, be-
fore and after the removal of the fixator and the K-wires, respectively.
H I G H L I G H T S

• Anatomical reduction at the emergency stage is not always necessary


After the second-stage operation, cefazolin 2000 mg per 12 hours or
for patients with open Lisfranc fracture-dislocations. cefuroxime 1500 mg per 8 hours was used for 24 hours if no sign
• The staged progressive reduction protocol using an adjustable bilateral of infection was noticed. Anticoagulant therapy with enoxaparin 1
external fixator is a promising way to achieve and maintain anatomical mg/kg for every 24 hours started 12 hours after operation to prevent
reduction at a price of relatively low risk of wound complication for
open Lisfranc fracture dislocations. venous thrombosis. Thromboprophylaxis lasted usually for about
• Irritation of the anastomotic vessels can be avoided in patients with two weeks after the surgery. It stopped when the patient regained
Gustilo type IIIC cases with vascular impairment and anastomosis by adequate mobility either by weight bearing or removal of cast im-
performing the distraction process slowly and progressively after the
operation with intensive monitoring of the acral blood supply. mobilization. If venous thrombosis was found, therapeutic dose of
low-molecular heparin, that is, enoxaparin 1 mg/kg for every 12

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Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96

a b c d

Figure 2. a-d. Preoperative X-ray and CT images of the same foot in Figure 1, showing the fracture and displacement of the first, second, and third tarsometatarsal
joints and the talonavicular joint, and fracture of the cuboid

a b a b

Figure 4. a, b. Pictures of the foot in Figure 1 after the first-stage operation, show-
ing the setup of the bilateral fixator. Note that the soft tissue both in the (a) planta
pedis and (b) dorsalis pedis healed very well after the setup of the external fixator

were obtained at 1, 2, 3, 6, 9, and 12 months after the final operation,


followed by yearly radiograph imaging every year after. The patient
could return to the hospital anytime if he or she felt any discomfort in
Figure 3. a, b. Images of the foot in Figure 1 after immediate wound irrigation and the midfoot region. Complications such as infection, osteomyelitis, or
debridement, and the first-stage reduction and fixation with a bilateral external posttraumatic arthritis were evaluated. The radiographic criteria for
fixator. It could be noted that at this stage, the displaced talonavicular joint was
posttraumatic arthritis were the existence of sclerosis, osteophytes,
reduced, and the length of the disrupted columns was restored by the external fix-
ator. Note that only the length of the disrupted columns and gross alignment were subchondral cysts, and/or joint space narrowing. The functional out-
restored, and anatomical reduction was not achieved at this stage comes were evaluated according to the visual analog scale (VAS) and
the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot
hours, was prescribed. The patient was told to stay in bed with his scale system at every follow-up (9).
or her leg elevated. Pressing, moving, or applying hot compresses to
the leg was prohibited. The injured limb was routinely elevated and Results
immobilized with a short leg cast for about two weeks. No cast was
used for patients in whom small unilateral external fixators were A total of 24 patients, including 18 men and six women, were re-
used to fix the comminuted columns. Two weeks later, the cast was cruited for the study. After screening, three patients were excluded
removed, and the patients were encouraged to do a range of motion from the study including one patient who was transferred to another
exercises without weight bearing until the 6th to the 8th week, when trauma center after the initial debridement and external fixation, one
patients started exercising with partial weight bearing within 10 kg patient with Gustilo type IIIC injury who received primary amputa-
on an arch support. The latter exercise was continued until the third tion, and another patient who failed to be contacted after discharge
month after the surgery with a gradually increased weight bearing due to invalid phone number on record. Finally, there were 21 pa-
to full dose. The arch support was used for about 3 months. During tients who participated in this study, including 16 men and 5 women,
the follow-up period, radiographs with AP, lateral, and oblique views with an average age of 44.4 years (range, 24 to 69 years). After dis-

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Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96

Table 1. Clinical information of the patients included


Case No. Age (y) Gender Side Gustilo Wound Hardcastle- Part of injury Cause of injury TFID
type closure Myerson type (hr)
1 31 M L IIIB skin graft C2 Calcaneal fracture, calcaneal-cuboid subluxation, fracture of the medial Fall 3
and middle cuneiforms, fracture of the 1st metatarsal base, complete
medial displacement of the 1st metatarsal and lateral displacement of the
2nd to the 5th metatarsals.
2 36 M R IIIA Primary B2 Displacement between the medial and middle cuneiforms, fracture of the MCA/EMA 5
closure 2nd metatarsal base, lateral displacement of the 2nd to the 5th metatarsals.
3 47 F R IIIB Secondary C2 Fracture of the medial and middle cuneiforms as well as the 1st and 2nd PVA 6
closure metatarsal base, complete divergence between the 1st and 2nd metatarsals.
4 69 F L IIIB Skin graft B1 Fracture of the medial cuneiform, medial displacement of the 1st Crush injury 5
metatarsal.
5 52 M R II Primary B2 Fracture of the cuboid and lateral cuneiform, fracture of the 2nd metatarsal MCA/EMA 9
closure base, lateral displacement of the 2nd to the 5th metatarsals.
6 51 M L IIIA Skin graft A2 Fracture of the 1st metatarsal base, medial displacement of the 1st to the 5th PVA 7
metatarsals.
7 37 M R IIIC Flap B2 Fracture of the talus, dislocation of the subtalar and talonavicular joints, Crush injury 4
fracture of the medial, middle and lateral cuneiforms, fracture of the 5th
metatarsal base, lateral displacement of the 2nd to the 5th metatarsals.
8 43 F R IIIA Primary B2 Talo-navicular dislocation, calcaneo-cuboid subluxation, naviculo- MVA 7
closure cuneiform subluxation, fracture of the medial, middle and lateral
cuneiforms as well as the cuboid, fracture of the distal 2nd metatarsal
and proximal 5th metatarsal, lateral displacement of the 2nd to the 5th
metatarsals.
9 29 F L IIIB Flap B1 Fracture of the 1st metatarsal base, medial displacement of the 1st MVA 6
metatarsal
10 35 M R IIIB Flap C2 Fracture of the navicular, the medial cuneiform and the 1st metatarsal Crush injury 4
base, complete divergence between the 1st and 2nd metatarsals.
11 27 M L II Primary B2 Fracture of the 2nd metatarsal base, lateral displacement of the 2nd to 5th Fall 4
closure metatarsals.
12 61 M R IIIB Skin graft B2 Fracture of the 4th and 5th metatarsals and lateral displacement of the 2nd to PVA 5
the 5th metatarsals.
13 63 M L IIIA Primary B2 Fracture of the 2nd metatarsal base and the middle as well as lateral Crush injury 13
closure cuneiforms, lateral displacement of the 2nd to 5th metatarsals.
14 24 M L IIIB Skin graft B2 Displacement between the medial and middle cuneiforms, lateral Crush injury 8
displacement of the 2nd to the 5th metatarsals.
15 38 F R IIIB Skin graft C1 Fracture of the 1st and 2nd metatarsals, Complete divergence between the MVA 5
1st and 2nd metatarsals.
16 56 M R IIIB Secondary A1 Displacement of the naviculo-cuneiform joint, medial displacement of the PVA 4
closure 1st to 5th metatarsals.
17 59 M L IIIB Skin graft B2 Fracture of the 2nd and 3rd metatarsal base, lateral displacement of the 1st to MCA/EMA 6
5th metatarsals.
18 44 F R IIIA Primary C1 Fracture of the navicular and medial cuneiform, fracture of the 2nd MVA 4
closure metataral base, partial divergence between the 1st and 2nd metatarsals.
19 60 M L II Primary B2 Lateral displacement of the 2nd to 5th metatarsals. MCA/EMA 5
closure
20 32 M R IIIB Flap B2 Fracture of the medial cuneiform, fracture of the 5th metatarsal base, Crush injury 3
lateral displacement of the 2nd to 5th metatarsals.
21 39 M L IIIA Primay B2 Lateral displacement of the 2nd to 5th metatarsals. PVA 8
closure
MVA: motor vehicle accident; MCA: motorcycle accident; ECA: electrocycle accident; PVA: pedestrian versus automobile: TFID: time from injury to the first debridement

charge from the hospital, these 21 patients were followed up for an minutes) was the average time duration for the first-stage operation,
average period of 15.4 months (range, 12 to 24 months). The clinical which included maneuvers, such as wound irrigation and debride-
data of the patients are shown in Table 1. All the Lisfranc fracture ment, fracture reduction, external fixator installation, and VAC seal-
dislocations were unilateral. Among them, 6 patients suffered con- ing process if necessary. Gentamicin cement beads were embedded
comitant Chopart injury. The most common cause for the injuries in nine patients. Deep infection and superficial infection were found
was crushing, followed by pedestrian versus automobile accidents. in one and two patients, respectively. No osteomyelitis occurred in
Motorcycle/electrocycle accidents as well as motor vehicle accidents this study. Venous thrombosis was found in three patients. However,
were also frequently seen. According to the Gustilo-Anderson classi- all the thrombus achieved stable adherence to the vascular wall 2 to
fication system, there were 3 type II injuries, 6 type IIIA injuries, 11 3 weeks later upon treatment. In the patients, neither clinical symp-
type IIIB injuries, and 1 type IIIC injury, whereas according to the toms nor signs of pulmonary embolism were detected. The average
Hardcastle-Myerson classification system, there were 1 type A1 case, time duration from the first-stage operation to definitive internal fix-
1 type A2 case, 2 type B1 case, 12 type B2 cases, 2 type C1 cases, and ation was 18.6 days (range, 8 to 48 days). During this period, an av-
3 type C2 cases. None of the injuries were solely ligamentous. The erage of 2.5 operations were performed (range 1 to 5), most of which
average waiting time from injury to the initial debridement was 5.8 were repeated irrigation and debridement. After definitive fixation,
hours (range, 3 to 13 hours). Clinical outcomes of these patients are as shown in Table 3, no patient was found bearing displacement over
listed in Table 2. As shown in Table 2, 138.9 minutes (range, 98 to 193 2 mm in the Lisfranc joint region. The first metatarso-cuneiform step-

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a b c

Figure 5. a-c. Images of the foot in Figure 1 after the bilateral frame was removed, and the tarsometatarsal and the Chopart joints were anatomically reduced and
fixed. Excellent reduction and fixation with cannulated screws of the medial and the middle columns could be noted. The fractured talonavicular joint was transfixed
with a cannulated screw. For the comminuted lateral column, a small unilateral external fixator together with K-wires was used

Table 2. Clinical outcomes of the patients involved


No. of surgeries
Duration of the Time from Ex-Fix between Ex-Fix VAS at AOFAS at
Case first operation to definitive and definitive Primary Cement Follow-up the last the last Time of
No. (min) fixation (d) fixation arthrodesis Complication embedded period follow-up follow-up hospital stay
1 187 21 3 √ √ 12 4 73 25
2 122 12 1 15 1 84 16
3 134 16 2 √ 24 2 78 21
4 139 19 3 post-traumatic arthritis, 16 2 74 22
venous thrombosis
5 98 8 1 18 1 92 13
6 116 14 2 19 2 97 18
7 193 48 5 √ superficial infection, √ 12 5 63 56
venous thrombosis,
8 165 23 3 venous thrombosis √ 12 2 75 28
9 145 11 1 √ 12 1 90 14
10 147 13 2 √ 15 3 72 17
11 109 12 2 19 0 81 16
12 126 16 2 post-traumatic arthritis √ 12 3 73 19
13 153 28 4 Deep infection, post- √ 18 4 67 32
traumatic arthritis
14 144 21 3 √ 16 2 68 25
15 120 25 3 post-traumatic arthritis 18 3 75 27
16 147 14 2 post-traumatic arthritis 15 2 75 18
17 163 19 3 √ 12 5 64 23
18 134 17 3 post-traumatic arthritis 12 3 76 24
19 112 10 1 12 1 79 14
20 125 26 4 √ 16 2 76 31
21 137 17 2 √ Superficial infection √ 19 2 71 21

off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) 0 to 5). The average AOFAS score was 76.3 (range, 63 to 97). Signs
improved significantly. Seven cases had their TMT joints primarily of posttraumatic arthritis were found in six patients by postopera-
fused. At the last follow-up, the average VAS score was 2.4 (range, tive imaging at the end of follow-up. The initially achieved reduction

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Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96

was partially lost after removal of the internal fixation instruments


a b
in three patients, none of which were more than 2-mm displacement.
No significant change was noted in VAS and AOFAS scores in these
patients . Therefore, no additional surgical intervention was neces-
sary for these patients. Figure 6 illustrates a general view of the in-
jured foot with weight bearing in a typical case at the end of the fol-
low-up, which was 1 year after the second-stage operation. Figure 7
shows the X-ray images of the foot of the typical case in Figure 1 after
the removal of the external fixator. Figure 8 demonstrates the photo
images of the foot of the same patient a year after the second-stage
internal fixation surgery. Figures 9, 10 and 11 demonstrate the X-ray
radiographs of another typical case after the first stage operation, af-
ter the second stage operation and at the final follow-up respectively.

Figure 6. a, b. The photograph of the foot in Figure 1 after the second-stage op- Discussion
eration. Note that excellent wound healing was achieved in the (a) dorsalis pedis
and the (b) small unilateral external fixator still in place across the lateral column In this study, we investigated the outcomes of open Lisfranc fracture
in the lateral view
dislocations repaired with a staged and progressive protocol using
an adjustable bilateral external fixator. At the end of follow-up, the
a b c patients had a significantly improved first metatarso-cuneiform step-
off (p=0.002) and second metatarso-cuneiform step-off (p=0.000). The
average VAS score was 2.4, and the average AOFAS score was 76.3.
Furthermore, there were three infections in total, including deep in-
fection in one patient and superficial infections in two patients, all
of which occurred before the definitive fixation. The results of our
study suggest that open Lisfranc fracture dislocations, even those
injuries with concomitant vascular injuries, can be treated with the
staged and progressive reduction protocol to successfully restore
the length of the disrupted columns at the emergency stage and to
achieve an excellent reduction of the TMT joint alignment, pain re-
lief, and functional outcome, without increasing the risk of soft tissue
Figure 7. a-c. Images of the foot in Figure 1 after the removal of the external compromise and infection.
fixator, K-wires, and the cannulated screws transfixing the talonavicular joint 7
months later. The postoperative X-ray radiographs showed excellent alignment of Treatment of open Lisfranc fracture dislocations is challenging for
the tarsometatarsal joins but narrowed joint space and slightly decalcified bone.
The dislocated calcaneocuboid joint was reduced, though there was slight flat foot orthopedic surgeons because of the tenuous soft tissue envelope and
malformation the intolerance of nonanatomic alignment due to the highly specific

a b c

Figure 8. a-c. Images of the foot in Figure 1 a year after the second-stage internal fixation surgery. The general view of the weight-bearing foot shows excellent wound
healing in (a) dorsalis pedis, (b) excellent hindfoot alignment, and (c) acceptable height of the medial arch of the foot

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Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96

a b c anatomic and biomechanical feature of the midfoot region (10). Efforts


have been made to solve this problem with different strategies. At-
tempts of single-stage primary anatomic reduction and fixation, includ-
ing external frame fixation as the ultimate procedure, multiple K-wires
as the ultimate procedure, and simultaneous screw fixation with flap
coverage, were made in early studies. However, the outcomes of these
attempts were not satisfactory because various reasons such as unac-
ceptably high risk of persistent mobility (11), incompatibility of the
device (5, 12), insufficient stability of the used device, which led to a
Figure 9. a-c. Images of the X-ray radiograph of a 37-year-old male after the first-
high risk of flatfoot morbidity (4, 13-15), requirement of complicated
stage operation. It could also be noted that the displacement of the tarsometa-
tarsal joints and the malalignment of the fracture sites were not anatomically technique, risk of flap failure, and inadequate sample size (16).
reduced
Furthermore, Gu and Shi proposed a concept of staged management
a b c for open Lisfranc fracture dislocations. Their concept was similar to
the treatment for high-energy pilon fractures because these two types
of fractures shared similar features of intolerance of nonanatomic
reduction and the poor soft-tissue coverage (17). The application of
staged management for high-energy pilon fractures efficiently re-
duced the complication rate of the affected soft tissue (18, 19). In the
study conducted by Gu and Shi, satisfactory reduction was achieved
via the wound or with a joystick technique and provisionally stabi-
lized with K-wires at the first stage, then the K-wires in the medial
and middle columns were converted to screws for definitive fixation
at the second stage. This staged protocol provided enough time for
soft tissue to recover while the bony and articular alignment was sta-
bilized anatomically (17). In the current study, several modifications
Figure 10. a-c. Images of the X-ray radiograph of the same patient after the
second-stage operation. The external fixator was changed to internal fixation were made in the surgical protocol proposed by Gu and Shi. Not only
using cannulated screws and K-wires. It could be noted that the comminuted and the fixation, but also the reduction process was performed in a staged
displaced middle and lateral columns as well as the cuneonavicular joint were
manner. In our protocol, the only goal of the first stage was the resto-
anatomically reduced
ration of normal length and the gross alignment of the disrupted col-
umn or columns instead of direct meticulous anatomic reduction. To
a b c
achieve this goal, a bilateral adjustable external fixator was used. For
those cases with vascular injury and/or anastomosis, the first-stage
reduction maneuver was achieved via a slow and gradual distraction
process postoperatively using the external fixator to avoid irritation
of the vessel. The ultimate anatomic reduction maneuver and defin-
itive internal fixation were not performed until the recovery of the
soft tissue envelope to a status ready for closure or repair.

Our strategy has several advantages. First, by using the staged re-
duction protocol, the iatrogenic damage to the already injured soft
tissue envelope during the emergency stage can be minimized,
which would reduce the risks of soft tissue compromise and infec-
tion. Moreover, the duration of emergency operation can also be
Figure 11. a-c. Images of the weight-bearing X-ray radiograph of the same patient shortened, which would result in the shortening of wound exposure
at the last follow-up. The K-wires were removed. It could be noted that excellent
alignment and bony union were achieved in the disrupted middle and lateral col- time, consequently leading to a lower infection risk. This is espe-
umns in both the AP and the oblique views at this stage (a, b). In the lateral view, cially the case when the open Lisfranc fracture dislocation is just
it could also be noted that the normal height of the medial arch was maintained
even during full weight bearing
a part of severe, multiple injuries for which damage control is nec-
essary. Though the infection rate in our study was higher than that
in Gu and Shi’s study, it is notable that more Gustilo type IIIB and
Table 3. Radiographic outcome of the patients involved
IIIC cases were included in our study, suggesting that patients in our
Variable Pre-op Post-op p
First metatarso-cuneiform step-off (mm) 1.9±2.3 0.4±0.6 <0.05*
study were more severely injured. Conversion of K-wires to cannu-
Second metatarso-cuneiform step-off (mm) 3.4±1.5 0.7±0.3 <0.05* lated screws within the relatively short time reported by Gu and Shi
First intermetatarsal angle (deg) 8.9±2.8 8.4±1.6 0.39 in such badly injured and contaminated cases could be risky. It is
First metatarsal to talus angle (deg) 10.7±1.9 11.8±3.8 0.10 also worth noting that for the secondary reduction, shortening is the
Fifth metatarsal to calcaneus angle (deg) 16.4±4.1 15.5±1.2 0.28 most difficult situation to be corrected because of the contracture of
Second metatarsal length (mm) 72.5±3.2 75.0±3.8 <0.05* the surrounding tissue, while other malalignments, such as shifting,
Foot length (mm) 247.2±10.2 247.8±10.3 <0.05* rotation, and angulation, are relatively easy to handle. Therefore,
Second metatarsal length/foot length (%) 0.29±0.02 0.30±0.01 <0.05* restoration and maintenance of the length of the disrupted column
“*” stands for difference with statistically significant difference
during the emergency stage will greatly benefit the later open reduc-

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Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96

tion and internal fixation (ORIF). This is the reason why progressive prophylaxis, even for Gustilo type III patients. This may lead to addi-
distraction with a spanning external fixator across the Lisfranc joint tionally higher risk of infection than there should be.
or/and Chopart joint is needed before ORIF for missed or subtle
Lisfranc injuries (7, 20). In the current study, although the included In conclusion, staged and progressive reduction protocol using an ad-
patients were more severely injured compared with Gu and Shi’s justable bilateral external fixator is a promising way to achieve and
report, the Lisfranc fracture dislocations were still anatomically re- maintain anatomic reduction, which is essential for good outcome in
duced after the second-stage operation without the occurrence of patients suffering from open Lisfranc fracture dislocations, with low
infection later on, and the average AOFAS score was even higher risk of wound complication.
than that reported by Gu and Shi. Despite that the AOFAS score Ethics Committee Approval: Ethics committee approval was received for this study
can be influenced by the measurement error and presence of oth- from the Biomedical Research Ethics Committee of West China Hospital of Sichuan
University (file number: 1.0; file year: 2019).
er concomitant injuries in the foot and ankle regions, it still seems
that postponing the anatomical reduction manipulation to the time Informed Consent: Informed consent was obtained from all the individual partici-
of wound closure or repair does not adversely influence the quali- pants included in the study.
ty of reduction and functional outcome. Another advantage is that Acknowledgments: We would like to thank our research assistant (Xia Tang) for con­
in the cases with vascular injury, progressive reduction with slow tacting the patients and providing us with the information we need.
and gradual distraction of the external frame could prevent exces-
Author Contributions: Concept - A.T.; Design - A.T., H.A.; Supervision - A.T., Ö.K.;
sive tension on the anastomotic vessels. Intensive monitoring and Materials - A.T., H.A., Ü.A., S.H., E.E., Ö.K.; Data Collection and/or Processing - A.T.,
immediate adjustment of the distraction force when necessary may H.A., Ü.A., S.H., E.E.; Analysis and/or Interpretation - A.T., Ö.K.; Literature Search -
A.T., H.A., S.H., E.E.; Writing Manuscript - A.T.; Critical Review - A.T., Ö.K..
give the anastomotic vessels a second chance to recover and reduce
the risk of vascular irritation and the necrosis of limb or local skin Conflict of Interest: The authors have no conflicts of interest to declare.
and/or subcutaneous tissue thereafter. The final advantage is that in
Financial Disclosure: The authors declared that this study has received no financial
those cases with significant comminution of the basal metatarsal re- support.
gion, K-wires may not be able to hold the arch height and the relative
length of the damaged columns because of the extreme instability of References
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