Our patient's pain was thought to be the result of both the degenerative changes and residual deformity causing abnormal stresses across her foot. She was prescribed physical therapy for muscle strengthening as initial conservative treatment.
Outcome studies regarding pediatric Lisfranc injuries are lacking. These injuries in themselves are rare and may be frequently overlooked because of skeletal immaturity and incomplete ossification making radiographic detection difficult.4 Many children can be treated nonsurgically with closed reduction and casting, and even with surgical intervention, short-term outcomes have generally been favorable, with patients having no limitations in athletic or everyday activities.3,7,8 However, studies suggest that long-term outcomes may be similar to those of adults. In adults, degenerative arthritis is the most common complication, with radiographic changes in 72% to 94% of patients, >50% of whom are clinically symptomatic.5,6 Unfavorable outcomes, including pain, arthritis, decreased functional activity, and orthotic requirements, have been associated with the poor quality of initial reduction or failure to maintain an anatomic reduction.1,5,9,10 However, degenerative changes and disability have been seen to occur even with appropriate treatment. One 10-year follow-up study found that 60% of patients with radiographic evidence of arthritis had no evidence of malalignment.5 Similarly in children, a study of adolescent Lisfranc injuries found persistent pain and discomfort in 6 of 7 patients treated with open reduction and internal fixation, with maintenance of reduction at 26-month follow-up.11 Several other studies have reported chronic pain in surgically treated pediatric patients as well, some with evidence of degenerative changes.7,8,12 The full extent of radiographic and bony changes in the pediatric population, however, has not been adequately described, and long-term outcomes into adulthood are unknown.
Our patient presented at 5-year follow-up with significant posttraumatic arthritis and fusion of the medial aspect of her midfoot. An anatomic reduction had been achieved, based on the surgical report and available postoperative radiographs; however, loss of reduction is a plausible explanation for our patient's deformity and symptoms. To begin with, the fixation she received did not follow standard principles. Typically, rigid fixation is used for stabilization of the medial and middle columns in the form of screws or plates, with flexible fixation reserved for the mobile lateral column.3,6,13 In this instance, flexible temporary K-wires were used as the sole mode of fixation. Smooth pins may have been used to protect the joint surfaces and open physes in a child, but this was potentially inadequate to hold the reduction. There was also no fixation placed across the Lisfranc joint proper or intercuneiform joints, where any subtle instability could lead to the development of arthritis and deformity.6 Loss of reduction or instability in our patient may also be attributed to early pin removal and initiation of full weight-bearing only at 4 weeks postoperatively. In one series, pediatric patients who received surgical treatment of bony Lisfranc injuries were kept non–weight-bearing for 11 to 14 weeks, whereas those treated nonsurgically for sprains were non–weight-bearing for 7 weeks.3 Adult patients treated surgically were typically non–weight-bearing for 6 to 8 weeks or longer as well. Despite this, one series showed that 4% of patients developed lateral subluxation after the initiation of weight-bearing, and these patients went on to develop posttraumatic arthritis.6,13 Even if reduction was maintained after pin removal in our patient, initiating weight-bearing so soon could have disrupted a very tenuous reduction.
The development of arthritic changes may be simply due to the injury itself. As previously mentioned, posttraumatic arthritis is the most common complication of Lisfranc injuries, even in those that maintain perfect reduction.5 The high-energy crush nature of our patient's injury likely caused traumatic cartilage damage as well as significant soft-tissue injury and stripping. Myerson et al10 found that direct crush injuries did particularly poorly, with seven of eight patients scoring poor on subjective functional outcome assessments. This damage could have also been perpetuated by the need for open reduction and débridement of the joint spaces.
There are unique properties of pediatric bone that must also be considered. Our patient had open physes at the time of injury, and any damage to the physis could lead to growth disturbance and subsequent deformity. Hill et al3 found Salter–Harris–type fractures present in 26% of patients with Lisfranc injuries and open physes, one of whom went on to develop physeal arrest. In addition, our patient had multiple attempts at closed reduction, finally requiring open reduction with soft-tissue dissection, putting the physes at further risk of iatrogenic injury. Physeal damage could have contributed to the development of our patient's shortened medial column and cavus foot. Uninjured physes may otherwise be expected to allow for some deformity correction as the patient grows. Alternatively, the healing potential of immature bone may contribute to bony overgrowth, leading to fusion and deformity in our patient's case. A study of pediatric spinal growing rods found that fusion occurred in 89% of patients in areas that had not been fused intentionally, likely because of “the proclivity of immature bone to rapidly and reliably heal fractures and, by extension, form spontaneous arthrodesis.”14 This is thought to be a consequence of periosteal stripping, whether traumatic or during surgical dissection, that decompresses the physis and allows for overgrowth and also influences metaphyseal remodeling.15–17 Although our patient ended up with some shortening, it is possible that overgrowth contributed to fusion in the face of damaged cartilage.
Lisfranc injuries in children are rare but seem to be comparable with their adult counterparts in both mechanisms and outcomes. Treatment in children should follow the same principles of rigid fixation and restricted weight-bearing as those used in adults, and excessive soft-tissue stripping during surgery should be avoided to protect the immature periosteum. As described throughout the literature, obtaining and maintaining an anatomic reduction remains a key factor in achieving good outcomes, although it cannot unequivocally prevent degenerative changes in the setting of articular cartilage or physeal damage. The development of a fusion in and of itself should be painless, but the resultant deformity may lead to metatarsalgia and adjacent joint arthritis. Even in the absence of degenerative changes, the foot should be assessed for any deformity, particularly in a child with known or suspected physeal injury. Our patient demonstrates that posttraumatic arthritis is a real concern after Lisfranc injuries in a growing foot and can lead to persistent pain, deformity, and decreased function. There is still a significant gap in the literature regarding the natural history, treatment, and outcomes of Lisfranc injuries in the pediatric population, and more long-term studies are needed to truly appreciate their sequelae.
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