Review Question - QID 3608

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Lisfranc Injury Treatment Operative QID: 3608 (OBQ11.185)

QID 3608 (Type "3608" in App Search)

A 40-year-old male sustains a right foot injury after a head-on motor vehicle collision. He is unable to place weight on the foot to ambulate due to pain along the medial aspect of the foot. The pain is exacerbated with abduction of the midfoot. The patient denies pain along the lateral border of the midfoot. He is neurovascularly intact in the foot. An injury radiograph is shown in Figure A, while a clinical image of the foot is shown in Figure B. What is the most appropriate next step in management?

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Open reduction and arthrodesis of the medial two tarsometatarsal joints

59%

2053/3494

External fixation of the foot followed with staged open reduction and screw fixation across the medial two tarsometatarsal joints

77/3494

Percutaneous reduction and wire fixation across the medial three tarsometatarsal joints

21%

744/3494

Debridement of Morel-Lavallee lesion and external fixation of the foot followed with staged open reduction and screw fixation across the medial two tarsometatarsal joints

24/3494

Open reduction and screw fixation across the medial two tarsometatarsal joints with anatomic ligamentous reconstruction

17%

578/3494

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The history, clinical images, and radiographs are consistent with a Lisfranc injury. Instability of the Lisfranc joint is the result of injury to both the interosseous first cuneiform-second metatarsal ligament (Lisfranc's ligament) and the plantar ligament between the first cuneiform and the second and third metatarsals.

Ly and Coetzee performed a Level 1 investigation of 41 patients with an isolated acute or subacute Lisfranc dislocation treated with ORIF or primary arthrodesis of the medial column of midfoot. 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). The postoperative level of activities was significantly higher in the arthrodesis group and 25% of the ORIF group required a subsequent revision to an arthrodesis. They concluded that primary arthrodesis of the medial two or three rays has a better short and medium-term outcome than ORIF.

Henning et al conducted a Level 1 investigation of 40 patients with a Lisfranc fracture/dislocation treated with either ORIF or primary arthrodesis. They found that nearly 80% of the ORIF group needed subsequent hardware removal compared to 15% of the arthrodesis group. They found no statistical difference in functional outcomes at nearly 4-year follow-up. They concluded that there is no significant difference in SF-36 and Short Musculoskeletal Function Assessment outcome scores when compared to ORIF.

The deep neurovascular bundle (as shown in Illustration A) should be protected following its identification after skin incision. Illustration B is an example of a tarsometatarsal arthrodesis with the medial three joints fused.

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