Review Question - QID 219469

This 38-year-old male suffered a combined osseoligamentous partial lateral dislocation Lisfranc injury (B2 subtype) following a motorcycle accident. The patient would likely experience inferior functional outcomes postoperatively as he received a complete tarsometatarsal arthrodesis.

A Lisfranc injury is characterized as a tarsometatarsal (TMT) fracture-dislocations between the articulation of the medial cuneiform and second metatarsal. Most injuries require operative fixation to some degree, depending on the type of injury. A significant amount of debate exists concerning open reduction, internal fixation (ORIF) versus primary arthrodesis, with the conclusion being both procedures provide similar outcomes (functional, complications, reoperations) when excluding the removal of hardware following ORIF. However, when electing for arthrodesis as the primary mode of fixation, temporary fixation of the lateral column (4th and 5th TMT joints) with k-wires is the standard due to the high mobility of these rays, and performing arthrodesis reduces motion and thus portends inferior functional outcomes.

Reinhardt et al. performed a retrospective study of 25 patients sustaining Lisfranc fracture-dislocations (12 purely ligamentous, 13 combined osseoligamentous) being treated with primary partial arthrodesis, and examining radiographic, clinical, and patient-reported outcomes at an average of 4.5 years. The authors found no difference in patient-reported outcomes between the two types of injuries, while 85% of all patients returned to their pre-injury activity level. The authors conclude that both types of injuries can be successfully treated with partial arthrodesis, with the expectation of successful functional outcomes.

Ly and Coetzee performed a prospective, randomized trial examining the clinical and radiographic outcomes between primary partial arthrodesis (n=21) and ORIF (n=20) at an average of 42.5 months follow-up. The authors observed a significant difference in American Orthopaedic Foot and Ankle Society, favoring arthrodesis (88 points) over ORIF (68.6) (p<0.005), while 25% of the ORIF group required subsequent conversion to arthrodesis. The authors concluded that partial arthrodesis of the 1st, 2nd, and 3rd TMT joints provides improved outcomes in the medium term compared to ORIF.

Russell and Ferdinand performed a review pertaining to the surgical management of 4th and 5th TMT joints. They note arthrodesis should be reserved for select patients with moderate-to-severe arthritis, citing the 4th and 5th TMT joints being critically important for load transfer/shock absorption during the gait cycle. While the authors report the procedure can expectedly improve pain, it is fraught with additional surgeries primarily addressing metatarsalgia. In conclusion, the authors cannot advocate for arthrodesis, citing the significant lack of literature on the procedure.

Figures 1-3 represent anteroposterior, oblique, and lateral plain radiographs demonstrating a combined osseo-ligamentous Lisfranc injury with lateral and dorsal dislocation of rays 2-5 with additional injuries involving the talonavicular and calcaneo-cuboid joints. While Figures 4 & 5 demonstrate CT reconstruction imaging of the aforementioned injury.

Incorrect Answers:
Answers 1, 3, 4, 5: Primary fusion of the lateral rays would lead to inferior functional outcomes secondary to limitations in motion.