Current Insights On Primary Tarsometatarsal Fusion For Lisfranc Injuries

While surgeons commonly employ open reduction and internal fixation for injuries to the tarsometatarsal joint complex, this author suggests that primary fusion offers a single-stage alternative with more stable, predictable outcomes over time.

Injuries to the tarsometatarsal joint complex (Lisfranc) are often associated with long-term disability and painful post-traumatic arthritis.¹ Treatment strategies have evolved over the years. Traditional treatment often consisted of closed reduction and immobilization, or closed reduction and percutaneous fixation. These methods often did not result in anatomic reduction and results were often unsatisfactory, leading to residual midfoot instability and limited functionality. Over time, the proposed treatment of Lisfranc injuries transitioned away from closed reduction and progressed toward open reduction and internal fixation (ORIF). This remains the current preferred management approach for these injuries.

Although ORIF remains the mainstay of treatment, results are often suboptimal.  Even with anatomic reduction and stable fixation, patient results often deteriorate over time. Typical fixation methods that surgeons employ include transarticular fixation with screws and, more recently, dorsal bridge plating.

When one uses transarticular fixation, removing the screws creates large osteochondral defects on both sides of the joint. These resultant cartilage defects may contribute to the high incidence of post-traumatic degeneration that is often present with these injuries after ORIF and screw removal. Dorsal bridge plating fixation constructs preserve the cartilaginous surfaces and afford similar functional outcomes and patient satisfaction. However, the use of dorsal bridge plating fixation often requires additional dissection. These plates are designed to be temporary and if the hardware remains after ORIF, there is essentially a nonunion, and this may cause prolonged discomfort.

Recently, the trend has been moving toward primary fusion for purely ligamentous injuries. In a prospective, randomized clinical trial, Ly and Coetzee compared primary arthrodesis with traditional ORIF for the treatment of primary ligamentous Lisfranc injuries and reported better short- and medium-term outcomes with primary arthrodesis.² In a comparable prospective, randomized study, Henning and colleagues found no significant difference in functional outcomes, clinical assessment and patient satisfaction between those treated with primary arthrodesis and those treated with ORIF for acute Lisfranc injuries.¹ The authors also found the rates of secondary surgeries between the ORIF and primary arthrodesis groups were 78.6 percent and 16.7 percent respectively.

This is not surprising as it is routine to remove screws and dorsal locking plates after ORIF. Therefore, the surgeon should consider the increased rate of hardware removal following ORIF along with its associated morbidities.

After ORIF of severe intra-articular fractures and subsequent hardware removal, incomplete fusion and joint degeneration may occur, leading to pain, which may require salvage arthrodesis. In this situation, one may consider primary fusion as an alternative to ORIF. This approach realigns and stabilizes the medial and central columns. These joints have been referred to as “non-essential” due to their limited motion and thereby, an arthrodesis will not affect the long-term function. Fusion also eliminates the potential of post-traumatic degeneration and the need for hardware removal.

I consider primary arthrodesis in select cases of acute injuries to the tarsometatarsal joint complex, particularly in purely ligamentous and severe intra-articular comminuted fractures.³ The following case demonstrates primary fusion for an acute tarsometatarsal fracture.

A Closer Look At The Patient Presentation And Surgery

A 48-year-old female presented to the emergency department after injuring her left foot. The patient described falling from a height and twisting her foot on impact. She immediately experienced significant pain and was unable to stand or ambulate. 

Upon clinical evaluation, she had localized pain to the tarsometatarsal joint complex. She had palpable pedal pulses and sensation was intact. 

I obtained radiographs including AP, lateral and medial oblique views of the foot as well as computed tomography (CT) imaging. Radiographs revealed an obvious tarsometatarsal fracture involving the bases of the second, third and fourth metatarsals. The CT scan allowed for a more detailed evaluation of the fracture pattern and revealed an intra-articular fracture at the base of the second metatarsal as well as a displaced distal fracture fragment. There were also comminuted intra-articular displaced fractures of the third and fourth tarsometatarsal joints.

I delayed surgery until the skin lines returned and after appropriate medical workup and optimization, she went to the operating room. Using a two-incision approach, I anatomically reduced the second and third tarsometatarsal fractures, and performed primary fusion using dorsal locking plates. The fourth tarsometatarsal had anatomic reduction and I fixated it with a 0.062 inch Kirschner wire.

Postoperatively, the patient wore a compressive dressing, was immobile in a posterior splint and was non-weightbearing with crutches. After two weeks, I removed sutures and she wore a well-padded, short leg cast and remained non-weightbearing. At four weeks, I removed the cast and she wore a controlled ankle motion (CAM) boot and remained non-weightbearing. After six weeks, progressive weightbearing in CAM boot started and at eight weeks, I removed the K-wires in the office. The patient transitioned to supportive sneakers and progressed well. She returned to normal activities and remains pain-free.

In Conclusion

Injuries to the tarsometatarsal joint complex are associated with long-term disability from painful post-traumatic arthritis and deformity. Open reduction and internal fixation remains the treatment of choice for most of these injuries. A trend toward primary fusion is happening, especially for purely ligamentous injuries and severe, intra-articular fractures.³ Primary fusion is a single-stage approach with less need for secondary surgery. Fusion outcomes will remain stable over time with predictable results whereas ORIF results will likely deteriorate over time as post-traumatic arthritis develops.

Dr. Bevilacqua is in private practice at North Jersey Orthopaedic Specialists in Teaneck, NJ. He is board-certified in both Foot Surgery and Reconstructive Rearfoot and Ankle Surgery by the American Board of Foot and Ankle Surgery. Dr. Bevilacqua is a Fellow of the American College of Foot and Ankle Surgeons.

References

1. Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG. Open reduction, internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009; 30(10):913-22.
2. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006; 88(3):514-20.
3. Bevilacqua NJ. Tarsometatarsal arthrodesis for Lisfranc's injuries. Clin Podiatr Med Surg (in press).