Fractures and fracture dislocations of the tarsometatarsal joint

FRACTURES AND FRACTURE DISLOCATIONS
OF THE TARSOMETATARSAL JOINT
JOURNAL CLUB
PRESENTER: DR. MURUGESH M. KURANI
CHAIR-PERSON: DR. M Y PATIL
Department of Orthopaedics, J N Medical
College, Belagavi.

Journal Of Bone And Joint Surgery,
VOL. 70-A, FEB 1988
CRAIG T. ARNTZ et. al
University of Washington School of Medicine,
Seattle

INTRODUCTION
Lisfranc injury is an injury of the foot in which one or more of the
metatarsal bones are displaced from the tarsus.
The injury is named after Jacques Lisfranc de St. Martin, a French
surgeon and gynaecologist who described the injury in 1815, after
the war of the sixth coalition.
LISFRANC joint injuries ( tarsometatarsal dislocations or fracture-
dislocations) are uncommon (0.2%), and they are frequently missed
or misdiagnosed.
However, even with accurate diagnosis and early treatment, these
injuries can result in chronic disability.

Over the past several decades, Lisfranc complex injuries have been
treated with closed reduction and immobilization, closed reduction
and pinning or open reduction and percutaneous pinning or screw
fixation.
However method of treatment is still controversial. Currently, the
recommended and accepted treatment of Lisfranc complex injuries
is open reduction and internal fixation, but, despite appropriate
initial treatment, painful osteoarthritis still develops in some
patients, necessitating conversion to an arthrodesis of the
tarsometatarsal joints to achieve pain relief.

Classification of tarsometatarsal
fracture-dislocations.
Quénu and Küss
Lateral Dorsoplantar
Type A: Total incongruity

Medial
dislocation
Type B1: Partial incongruity
Lateral
dislocation
Type B2: Partial incongruity

Partial
displacement
Total
displacement
Type C1: Divergent Type C2: Divergent

AIM:
TO ASSESS : Prospectively,
The functional and radiological outcomes, and
The prevalence of complications,
after early operative intervention in patients b/w 17 and 58
years of age with acute displaced fractures and fracture
dislocations of the TARSOMETATARSAL joint.
Study adopted an operative protocol of open reduction and
fixation using AO SCREW implant to maintain reduction
until union of the fracture.

MATERIALS AND METHODS:
STUDY DESIGN:
A hospital based prospective study
SAMPLE SIZE: 41
INCLUSION CRITERIA:
Patients with a displaced fracture and fracture
dislocations of the tarsometatarsal joints.
Medically fit, aged b/w 17 and 58 yrs who were seen
within FOUR weeks of the injury were considered.

28 men and 12 women were included in the
this study.
left foot: In 17 patients
right foot: in 22 patients
both feet: in 1 patient

MODE OF INJURY:
Automobile accidents: 9
Motorcycle accidents: 12
Fall from a height: 7
From a fall at ground level: 8
Some other accidents: 5

14 patients had concomitant life threatening
intracranial, thoracic, or abdominal injuries, or
a combination of such injuries. 19 patients
also had sustained fracture of a long bone in
the ipsilateral limb.

7 patients had an open, grossly contaminated injury. 2 of these
fractures were grade II (limited periosteal stripping), and 5 grade III
(extensive periosteal stripping). All but 1 of 5 patients had a severe
degloving injury, 2 of which involved considerable loss of plantar
skin. In all 7 tarsometatarsal injury included a comminuted fracture
and an intra articular injury to the cartilage.
6 out of 7 who had open fracture required at least one delayed split
thickness skin graft to achieve total epithelialization of the wounds.
Most of the complications in the series occurred in these seven
patients.

Injuries were classified radiographically according to
the system of Quénu and Küss.
Out of 41 injuries,
21 are Homolateral (all metatarsals are displaced in the
same direction).
14 are partial (one or more metatarsal sare displaced)
06 are divergent (the metatarsals are displaced in the
sagittal or in the coronal plane, or in both)

Intra articular and osteochondral fractures of the
displaced tarsometatarsal joints are observed
intraoperatively.
Gross injury to articular surfaces was identified in
association with 22 of the 41 fractures. Fracture
of a metatarsal or a cuneiform with or without
intra articular extension was observed in 35
patients.

OPERATIVE TECHNIQUE
With the patient under a regional or general
anaesthetic,
Make a dorsal incision lateral to the extensor
hallucis longus tendon over the interval between
the base of the first and second metatarsals,
slightly more lateral if access to the third
tarsometatarsal joint is necessary. At the distal
extent of the excision, preserve the most medial
branch of the dorsal medial cutaneous nerve.

A second incision may be
needed more laterally if
open reduction of the
fourth and fifth
tarsometatarsal joints is
necessary. Locate and
incise the inferior
extensor retinaculum.

Isolate the dorsalis pedis
artery and deep peroneal
nerve, and use a vessel loop
for retraction of these
structures medially or laterally
to allow inspection of
different areas of the Lisfranc
joint. Remove any debris from
the Lisfranc region between
the base of the second
metatarsal and the medial
cuneiform to allow the space
to be reduced.

Reduce the first
tarsometatarsal joint and
hold it with guidewires for
cannulated screws. Place a
screw from the dorsal aspect
of the first metatarsal into
the medial cuneiform. A
second screw can be placed
from proximal to distal
across the first
tarsometatarsal joint.

Under fluoroscopic guidance, pass a guidewire
from the medial cuneiform into the base of
the second metatarsal while holding the
reduction with a towel clip. Place the
appropriate 4.0-mm cannulated screw over
the guidewire.

The second and third metatarsal–cuneiform
joints can be reduced and fixed similarly with
one screw across the joint. Close the dorsal
skin with interrupted nylon sutures.

PRE AND POST OPERATIVE RADIOGRAPHS OF ONE OF THE PATIENTS
INCLUDED IN THE STUDY

POSTOPERATIVE CARE
Patients are restricted to partial weight bearing
(50 pounds) for 6 weeks. Then a below the knee
weight bearing cast used, with full weight bearing
allowed as tolerated, for an additional 4-6 weeks.
Depending on the patient’s age and the severity
of the injury, the total duration of immobilization
in a cast was 9-12 weeks. Afterwards, a support
stocking and a protective shoe were worn.

The internal fixation was maintained until
radiographs showed evidence of osseous
union. Screws are removed on an average of
16 weeks (range, 12-20 weeks) after injury.

RESULTS:
For 34 of 40 patients (35 of the 41 injuries), the length
of follow up averaged 3.4 years. 4 patients lost to
follow up and 2 patients were died after 1 year follow
up which time they had no complaints related to the
foot.
For the analysis of results, the patients are divided into
2 groups,
Group I: patients with closed injury (34)
Group II: patients with open injury (07)

In group I, alignment of the articular surfaces
was anatomically or near anatomically
restored in all but one patient. That patient
had minimum residual displacement that was
associated with substantial articular injury and
periarticular osseous comminution. 15 (45%)
of the 34 injuries included an intra articular
fracture.

In group II, anatomical or near anatomical
reduction was achieved in 3 of 7 patients. 3 of
remaining 4 patients had minimum
displacement and one had moderate
displacement. Marked articular and
periarticular osseous comminution was
identified in each of the 7 patients.

At the time of final follow up patients and their physicians rated the
result as,
Excellent: if, there was no disability or limitation.
Good: if, occasional slight limitation that did not interfere with
walking, or with the ability to work, to enjoy athletic activity, or to
walk on the toes easily.
Fair: if, activities were restricted, gait was normal, and the patient
was able to work but found participation in sports and walking on
the toes difficult.
Poor: if, there was limitation during daily activities and the patient
was unable to walk on the toes.

In group I, 29 patients completed full follow up, out of which,
11 had excellent, 16 had good functional result, remaining 2 rated
as fair.
In group II, 6 patients completed full follow up, out of which,
2 rated as good, 2 as fair and 2 as poor.
All of the cosmetic results were excellent or good in Group I. In
group II, 2 cosmetic results were fair who had damage to soft tissue
and loss of skin that required a split thickness skin graft for final
closure of the wound and 2 were poor had a grade 3 degloving
lesion that required a large split thickness skin graft to obtain final
coverage of the wound.

In group I, 11 patients had mild to moderate
post operative arthritis.
In group II, all 6 patients had moderate to
severe post operative arthritis in the form
joint space narrowing, formation of
osteophytes, appearance of sclerosis.

COMPLICATIONS:
In group I, 2 patients had post traumatic compartment
syndrome in the foot and patients underwent immediate
surgical decompression and internal fixation. Closure of
skin achieved 5 days later with a split thickness skin graft.
In group II, one patient developed marked contracture of
the skin graft and a cock-up deformity of the 4th and 5th toe
and in the other, an eqinovarus deformity developed in the
hind foot and secondary supination deformity in the fore
foot. These two deformities were secondary to a
compartment syndrome, which was a complication of a
grade II open fracture of the tibia.

DISCUSSION:
Recently it has been evident that, for many types
of dislocations and fractures, open treatment
yields better results than closed treatment
because it achieves and maintains an anatomical
reduction.
Incomplete reduction of the fracture or
dislocation, or redislocation after inadequate
treatment, frequently results in permanent
disability in the form of chronic pain, deformity,
and difficulty with wearing shoes.

The findings of the prospective study support the
premise that anatomical reduction is critical for
optimal results. An over-all good or excellent functional
result was obtained in about 95% of this study.
Under direct inspection, it is found that these displaced
fragments of bone and torn soft tissue often prevented
reduction. Because full reduction requires reduction of
these fragments and debridement of the soft tissue, it
is believed that surgical exploration and reduction is
the only reliable way to ensure restoration of the
congruence of the surfaces of the joint.

However, experience revealed multiple problems with
Kirschner wires, including migration of pins, infection
of pin tracts, and most importantly loss of reduction.
Other studies reported similar difficulties with
redislocation after fixation with kirschner wires.
This study results have shown that fixation of an
unstable tarsometatarsal joint with AO screws provides
the needed stability and has an additional advantage
over fixation with Kirschner wires.

There is little experience with the treatment of injuries
to the tarsometatarsal joints by primary arthrodesis, as
advocated by Granberry and Lipscomb.
That regimen may be indicated when the articular
surfaces have been severely damaged, but the
excellent results in this study suggest that primary
arthrodesis, even when such damage is evident, is not
necessary in the majority of patients.
Secondary arthrodesis can always be reserved for
patients who have persistent symptoms.

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Fractures and fracture dislocations of the tarsometatarsal joint