Closed Reduction and Percutaneous Fixation of Lisfranc Injury Using Suspensory Fixation

Abstract

Background: 

This closed reduction and percutaneous fixation (CRPF) technique utilizing suspensory fixation is indicated for the treatment of Lisfranc injuries with displacement or instability of the tarsometatarsal joint complex—and typically only for low-energy, purely ligamentous Lisfranc injuries. The goal of this procedure is to restore joint stability and prevent common complications of Lisfranc injuries (e.g., midfoot arch collapse and posttraumatic arthritis) while avoiding the complications and risks associated with open reduction and internal fixation (ORIF) and primary arthrodesis. We recommend performing the procedure within 10 to 14 days of the injury; otherwise, an open debridement may be necessary to address scar tissue formation.

Description: 

We start with the patient in the supine position and perform a fluoroscopic stress examination of the joint. Next, the Lisfranc joint undergoes closed reduction, which is held in place with a clamp. Following reduction, a guidewire is drilled from the lateral border of the base of the 2nd metatarsal medially through the medial cuneiform, followed by a medial-to-lateral cannulated drill. The suspensory fixation is then passed lateral-to-medial, placing the suture button on the lateral cortex of the 2nd metatarsal base. The tape is then tensioned while a bioabsorbable interference screw is inserted to maintain tension.

Alternatives: 

Prior studies have assessed both operative and nonoperative alternatives to CRPF with suspensory fixation for the treatment of Lisfranc injuries. Nonoperative treatment with closed reduction and cast immobilization of Lisfranc injuries is typically reserved for nondisplaced injuries; however, a number of studies have shown poor outcomes with use of this technique^1–3. The 2 most common operative alternatives are ORIF and primary arthrodesis⁴.

Rationale: 

CRPF with suspensory fixation offers several benefits over both traditional surgical techniques such as ORIF and primary arthrodesis, as well as over percutaneous reduction and internal fixation (PRIF) with a screw. Compared with ORIF and primary arthrodesis, a number of studies have shown that percutaneous treatment of Lisfranc injuries minimizes soft-tissue trauma and reduces the risk of postoperative complications such as wound breakdown, infection, and complex regional pain syndrome, while allowing for earlier participation in rehabilitation^5–10. A systematic review of outcomes following PRIF with screw fixation also showed that percutaneous treatment of Lisfranc injuries is a safe and effective technique with good functional outcomes¹¹. When comparing PRIF with a screw to our technique of CRPF with suspensory fixation, CRPF has the added benefit of creating a nonrigid fixation in the Lisfranc joint, which allows for increased range of motion of the medial column and improved return to activity^12,13. The rigid fixation in PRIF with a screw can also lead to metal irritation, intra-articular screw fracture, and impaired mobility, which often necessitate the need for screw removal^13–15. This fixation-related drawback is not present with our technique, and also avoids the need for use of a biologic substitute such as tendon grafts¹³.

Expected Outcomes: 

Following CRPF with suspensory fixation, patients can expect to return to full activity at 12 to 16 weeks postoperatively. Postoperatively, patients are typically kept non-weight-bearing for 6 weeks. The operative foot is kept immobilized in a splint for the first 2 weeks, then transitioned to a boot. Between postoperative weeks 6 and 12, partial progressive weight-bearing is introduced with use of an arch support, progressing toward full weight-bearing^13,16,17.

For comparison, patients who underwent PRIF with screw fixation had a similar postoperative course, but almost all required screw removal at 4 to 6 months postoperatively^13,16. Cho et al. retrospectively reviewed the results of 63 patients who underwent either PRIF with screw fixation (n = 32) or CRPF with a suture button (n = 31) and found that CRPF patients had significantly better American Orthopaedic Foot & Ankle Society midfoot scale scores (81 versus 74 points) and visual analog scale scores (3.1 versus 4.6 points) at 6 months postoperatively and prior to screw removal in the PRIF group (p < 0.001). There were no significant differences in these scores, radiographic outcomes, weight-bearing analysis, or complications at 1 year postoperatively. The authors concluded that both techniques provided comparable fixation stability and clinical outcomes. Of note, however, the PRIF group had 4 patients whose postoperative course was complicated by screw breakage¹³.

Important Tips: 

• Start with a fluoroscopic stress examination to identify all components of instability.
• Ensure that the reduction clamp does not interfere with or affect your guidewire path.
• If the joint cannot be reduced, convert to an open procedure and debride the obstruction.

Acronyms and Abbreviations: 

• ORIF = open reduction and internal fixation
• PRIF = percutaneous reduction and internal fixation
• CRPF = closed reduction and percutaneous fixation
• NSAID = nonsteroidal anti-inflammatory drug
• OR = operating room
• AP = anteroposterior
• CT = computed tomography
• MRI = magnetic resonance imaging
• AOFAS = American Orthopaedic Foot & Ankle Society
• VAS = visual analog scale
• ROM = range of motion
• PT = physical therapy
• ASA = acetyl-salicylic acid (aspirin)
• BID = twice daily
• PRN = as needed