Staged surgical treatment of open Lisfranc fracture dislocations using an adjustable bilateral external fixator: A retrospective review of 21 patients

Abstract

Objective: The aim of this study was to assess the early operative results of a staged progressive reduction technique using a bilateral external fixator in the treatment of patients with open Lisfranc fracture dislocations.

Methods: In this retrospective study, 21 patients (5 women and 16 men; mean age=44.4 years; age range=24 to 69 years) with open Lisfranc fracture dislocations were included. All the patients were treated in a staged manner from 2012 to 2015. The mean follow-up was 15.4 months (range=12 to 24 months). A two-stage surgical protocol was performed for each patient. At the first 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 removed, and open reduction and internal fixation were carried out. The time interval between the first and second stages and postoperative complications were documented. To assess the functional status of the patients, the visual analog scale (VAS) and the American Orthopaedic Foot - Ankle Society (AOFAS) midfoot scale were measured at the final follow-up. Radiographic parameters indicating the alignment of the midfoot after the second operation were examined.

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-cuneiform step-off (p=0.002) and the second metatarso-cuneiform step-off (p=0.000) significantly improved at the final follow-up. The 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 in seven patients, and six of the remaining 14 patients developed post-traumatic arthritis.

Conclusion: With a low risk of complications, the staged progressive reduction protocol using an adjustable bilateral external fixator can be an effective treatment to achieve and maintain anatomic reduction for patients with open Lisfranc fracture dislocations in a short-time follow-up.

Level of evidence: Level IV, Therapeutic study.

Figure 1. a, b

A typical open Lisfranc injury in the current study. A 43-year-old female patient got injured in a car accident. The pictures show the injury with contusion, laceration, and contamination of the right (a) planta pedis and (b) dorsum pedis

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

Figure 3. a, b

Images of the foot in Figure 1 after immediate wound irrigation and debridement, and the first-stage reduction and fixation with a bilateral external fixator. It could be noted that at this stage, the displaced talonavicular joint was reduced, and the length of the disrupted columns was restored by the external fixator. Note that only the length of the disrupted columns and gross alignment were restored, and anatomical reduction was not achieved at this stage

Figure 4. a, b

Pictures of the foot in Figure 1 after the first-stage operation, showing 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

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

Figure 6. a, b

The photograph of the foot in Figure 1 after the second-stage operation. 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 the lateral view

Figure 7. a–c

Images of the foot in Figure 1 after the removal of the external fixator, K-wires, and the cannulated screws transfixing the talonavicular joint 7 months later. The postoperative X-ray radiographs showed excellent alignment of the tarsometatarsal joins but narrowed joint space and slightly decalcified bone. The dislocated calcaneocuboid joint was reduced, though there was slight flat foot malformation

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

Figure 9. a–c

Images of the X-ray radiograph of a 37-year-old male after the first-stage operation. It could also be noted that the displacement of the tarsometatarsal joints and the malalignment of the fracture sites were not anatomically reduced

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 using cannulated screws and K-wires. It could be noted that the comminuted and displaced middle and lateral columns as well as the cuneonavicular joint were anatomically reduced

Figure 11. a–c

Images of the weight-bearing X-ray radiograph of the same patient 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 columns in both the AP and the oblique views at this stage (a, b). In the lateral view, it could also be noted that the normal height of the medial arch was maintained even during full weight bearing