Lisfranc Abierta
Lisfranc Abierta
Lisfranc Abierta
www.aott.org.tr
Research Article
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.
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
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.
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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
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Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96
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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Liu et al. / Acta Orthop Traumatol Turc 2020; 54(5): 488-96
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
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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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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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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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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