Tag Archives: dislocation

Complex Talonavicular Fracture Dislocation: A case report

by J. Terrence Jose Jerome, MBBS, DNB (Ortho), MNAMS (Ortho)1 , Mathew Varghese, M.S. (Ortho)2 , Balu Sankaran, FRCS (C), FAMS3

The Foot and Ankle Online Journal 3 (9): 1

Isolated talonavicular dislocation is rare because of the strong plantar ligamentous structures that support the joint. It appears that plantarflexion and inversion of the foot is the mechanism of injury. Very often, the strong spring ligament or plantar calcaneonavicular ligament is injured. Surgical repair is often the desired treatment in case of ligamentous injury. In this case, closed reduction with percutaneous pinning is presented as an alternative to open surgery. Early anatomical reduction is the key to preventing long term complications such as midtarsal joint arthritis and faulty foot mechanics.

Key words: Talonavicular fracture, dislocation.

Accepted: August, 2010
Published: September, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0309.0001


Complex talonavicular fracture dislocation is a rare injury of the foot. This region is usually resistant to injury because of the strong ligamentous structures around the midtarsal joint. The strongest ligamentous structures of the midtarsal joint are on the plantar side which is protected by the long and short plantar ligament, bifurcate ligament, and the plantar calcaneonavicular (spring) ligament, which are important as supports for the arch of the foot. [1]

Therefore, dorsal midtarsal dislocation resulting from disruption of these plantar ligaments is less common than other types of midtarsal dislocation. Kennedy reported a case of navicular fracture dislocation which, by the description of the incident and the reduction maneuver employed, suggests that plantarflexion combined with inversion were the forces required to produce the deformity. He also concluded that understanding of the mechanism of injury in these fractures may lead to easier closed reduction and improved outcome. [2]

Surgical repair of the short plantar ligament, bifurcate ligament and plantar calcaneonavicular or spring ligament is the desired approach to treatment and reducing the dislocation. However, closed reduction using percutaneous pin fixation appears to also be a viable option to open surgical treatment.

Case Report

A thirty five year-old male came to our patient department with history of fall from height injuring his right foot. There was diffuse swelling, and tenderness; crepitus was felt within the talonavicular joint. Radiograph shows a complex talonavicular dislocation. (Figs. 1 and 2)

Figure 1 The dorsoplantar view showing talonavicular dislocation.

Figure 2   Lateral view showing talonavicular dislocation with associated complex fracture.

Closed reduction of the talonavicular dislocation was performed under spinal anesthesia and stabilized by two percutaneous K-wires using image intensifier. (Figs. 3 and 4) The post operative period went uneventful. The patient was immobilized in a plaster of paris cast for six weeks. Gradual physiotherapy was performed to the ankle and foot.

Figure 3   Dorsoplantar view showing stable cross K-wire stabilization of the dislocation.

Figure 4   Lateral view showing stable cross K-wire stabilization of the dislocation.  Manipulation of the foot has also reduced the fracture fragment.

The post-operative period went uneventful. The patient was immobilized in a plaster-of-paris cast for six weeks. Gradual physiotherapy was performed to the ankle and foot.

The cast and surgical pins were removed after six weeks. Tolerable weight bearing ambulation began at eight weeks. The patient made a quick recovery and was allowed to fully weight-bear at twelve weeks.

He returned to his previous job without incident and no long term complication was identified. After a 2 year follow-up, no complications were reported. This patient is still successfully employed as a manual worker performing normal activities.

Discussion

Midtarsal joints, including the talonavicular and calcaneocuboid joints, are functionally related to the subtalar and Lisfranc joints. Isolated midtarsal injury is uncommon. Main and Jowett classified a series of 71 midtarsal joint injuries into 5 groups according to the direction of the deforming force and the resulting displacement: medial forces, longitudinal forces, lateral forces, plantar forces, and crush injury. [3] Only two cases of midtarsal dislocation were reported: pure plantar midtarsal dislocation and plantar subtalar dislocation associated with plantar dislocation of the talonavicular joint caused by a plantar force.

Cases of isolated midtarsal dislocation in medial, lateral, or plantar directions have been reported. [4–7] In this case, dorsal forces disrupted the plantar ligamentous structure, resulting in dorsal midtarsal dislocation.

The combination of dorsal dislocation of the navicular from the talus and an associated comminuted fracture of the calcaneus (transcalcaneal, talonavicular dislocation) is an unusual and severe injury and six cases have been described previously. [8] Midfoot fractures, particularly fracture dislocation injuries, affect the function of the entire foot in the long-term outcome.

Even in these complex injuries, an early anatomic reduction and stable fixation can minimize the percentage of long-term impairment. [9,10] A swivel dislocation is an uncommon variant of a subtalar dislocation, where a medially or laterally directed force dislocates the talonavicular joint, and subluxates but does not dislocate the subtalar joint. The calcaneus rotates or swivels on an intact interosseous talocalcaneal ligament without tearing it. It is important to recognize this injury as the treatment and prognosis are different form a subtalar dislocation. [11]

Complex talonavicular fracture dislocation causes residual insufficiency of plantar ligamentous structures and results in the plantar opening of the joint space. This will lead to increased compression stress on the dorsal part of the joint, resulting in dorsal ossification. Early midtarsal joint subluxation and arthritis, secondary to the residual insufficiency of the plantar ligaments are long-term complications.

Open reduction and internal fixation gives a better outcome allowing repair of the plantar ligamentous structures, especially the plantar calcaneonavicular or Spring ligament. This improves the stability of the talonavicular joint, which is critical to normal foot biomechanics. Primary fusion of the talonavicular joint after fracture dislocation of the navicular bone is also described. [12]

Conclusion

Complex talonavicular dislocation is rare. It represents a severe injury to the plantar ligamentous structures. An early anatomic reduction and stable fixation can minimize the long-term impairment. In our case, a closed anatomical reduction was achieved by closed reduction and stabilized by two percutaneous K-wires to minimize surgical trauma to the soft tissue. The K-wires were kept in place for six weeks. The reduction appeared satisfactory. After reduction, the patient was kept non-weight bearing and gradually returned to full weight-bearing after eight weeks. He went back to his manual work with normal activities and occasional pain to the foot.

References

1. McMinn RMH. Last’s Anatomy: Regional and Applied. 8th edition. London: Churchill Livingstone; 1990 204–217.
2. Kennedy JG, Maher MM, Stephens MM. Fracture dislocation of the tarsal navicular bone: a case report and proposed mechanism of injury Foot and Ankle Surgery 1999 5 (3): 167-170.
3. Main BJ, Jowett RL. Injuries of the midtarsal joint. J Bone Joint Surg 1975 57B: 89-97.
4. Ruthman JC, Meyn NP. Isolated plantar midtarsal dislocation. Am J Emerg Med 1988 6: 599-601.
5. Gaddy B, Perry CR. Chopart dislocation: a case report. J Ortho Trauma 1993 7: 388-390.
6. Hosking KV, Hoffman EB. Midtarsal dislocations in children. J Paediatr Orthop 1999;19:592–5.
7. Milgram JW. Chronic subluxation of the midtarsal joint of the foot: a case report. Foot Ankle Int 2002 23: 255-259.
8. William RM, Carlo Bellabarba C, Sanders R. Transcalcaneal talonavicular dislocation. J Bone Joint Surg 2002; 84A: 557-561.
9. Richter M, Wippermann B, Krettek C, Schratt HE, Hufner T, Therman H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int 2001;22:392–8.
10. Richter M, Thermann H, Huefner T, Schmidt U, Goesling T, Krettek C. Chopart joint fracture-dislocation: initial open reduction provides better outcome than closed reduction. Foot Ankle Int 2004 25: 340-348.
11. Pillai A, Chakrabarti D, Hadidi M. Lateral swivel dislocation of the talo-navicular joint. Foot Ankle Surgery 2006 12(1): 39-41.
12. Johnstone AJ, Maffulli N. Primary fusion of the talonavicular joint after fracture dislocation of the navicular bone. J Trauma 1998 45(6):1100-1102.


Address correspondence to:Dr. J. Terrence Jose Jerome, MBBS.,DNB (Ortho), MNAMS (Ortho), FNB (Hand & Microsurgery)

Registrar in Orthopedics, Dept. of Orthopedics, St. Stephen’s Hospital, Tiz Hazari, Delhi 54, India.
Head Professor, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.
Registrar in Orthopedics, Department of Orthopedics, St. Stephens Hospital, Tiz Hazari, Delhi, India.

© The Foot and Ankle Online Journal, 2010

Surgical Correction of Subluxing Peroneal Tendons Utilizing a Lateral Slip of the Achilles Tendon: A case report

by Mark Mendeszoon, DPM, FACFAS, FAFAOM,1 , J. Todd McVey, DPM2, Adam MacEvoy, DPM3  

The Foot and Ankle Online Journal 2 (8): 3

Subluxation of the peroneal tendon can be either an acute or chronic condition. As an acute injury, it can quite often be misdiagnosed as a lateral ankle sprain. This case report describes a technique using the lateral slip of the Achilles tendon as a retinacular graft to repair subluxation and dislocation of the peroneal tendons.

Key words: Tubularization, Achilles tendon graft, modified Brostrom repair, subluxation, dislocation, peroneal tendons.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: July, 2009
Published: August, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0208.0003

 


The peroneal tendons course around the lateral ankle at the distal aspect of the fibula. These tendons which include the tendons of the peroneus longus and brevis move through a tunnel created of both fibrous and osseous structures. [2] The borders of this tunnel include the lateral malleolus, posterior talofibular ligament, calcaneal fibular ligament, and superior peroneal retinaculum. Both tendons run together until they are distal to the fibula where they split and enter separate sheaths. Most important to us is the superior peroneal retinaculum (SPR) which is the primary restraint to subluxation and dislocation of the peroneal tendons. [1,8,9]

 

First Described in 1803 by Monteggia, peroneal subluxation and dislocation can be categorized as either acute or chronic injuries. Most acute injuries are caused by a sudden dorsiflexion and inversion of the ankle while the peroneals are contracting. Acute injuries occur most often during sporting activities.

The most common injury occurs during downhill skiing. If the injury is left untreated, it can lead to chronic pain or ankle pain that will require surgical correction. Pain is caused by splitting or fraying of the peroneal tendons which occur when the tendon continues to sublux over the posterior lateral edge of the fibula causing micro tears to the tendon. Chronic injuries are also associated with patients who are prone to multiple ankle sprains. These sprains can lead to lateral ankle weakness which can lead to inflammation of the peroneal tendon sheath. [6,8,9] The sustained inflammation of the sheath can lead to weakening and stretching of superior peroneal retinaculum which will allow the peroneal tendons to leave the peroneal tunnel. Echard and Davis created a classification system for peroneal subluxation.

This system includes for subtypes which are as follows:

I-Periosteum is elevated form underlying malleolus.
II-Superior peroneal retinaculum is torn from the anterior insertion.
III-Superior peritoneal retinaculum is avulsed with a small piece of bone.
IV-Superior peroneal retinaculum is avulsed from posterior attachment and tendon dislocates.

Conservative treatment of this condition can be used however the literature shows there is a high failure rate for this course of action. [2] Most conservative treatment includes casting for 4-6 weeks. Other treatment includes taping which as a lower success rate than casting. Usually primary repair is indicated for tears in the tendon involving 50% or less. [11] Considering the majority of these patients are athletes, most want a speedy return to activity and expect a high success rate. [1,8,9,10]

Case Report

A male patient reported that he was racing his motocross bike when he landed a jump with his foot in an awkward position. He recalls extreme pain at his ankle and noted that a bone was protruding under his skin, which he states that he pushed the bone back in to place and went to the emergency room (ER).

At the ER it was noted that patient had significant swelling, pain on palpation, ecchymosis, popping sensation along with extreme instability. Patient was immobilized, obtained a magnetic resonance image (MRI) and sent to the office the next day for consultation. After educating the patient on conservative and surgical options, the patient chose the latter. MRI showed extreme poster lateral edema, and anterior talofibular ligament (ATFL) tear, avulsion fracture of fibula, with a high suspicion of SPR tear.

Clinical evaluation reveals a 5’11” male who is 195 lbs. The patient’s neurovascular status remains intact. There is significant ecchymosis, positive Mondor sign, pain on palpation of fibula, pain with range of motion and the fibula is mobile at the lateral ankle. Stress films in the operating room while the patient is under general anesthesia reveals a positive anterior drawer and talar tilt.

Surgical Technique

An incision is made over the lateral aspect of the leg following the peroneal tendons, approximately 10-12cm in length. (Fig 1.) Significant hematoma and disruption of the tissue is encountered during blunt dissection. The peroneal tendon sheath is completely ruptured, and the peroneus brevis is lying on top of the lateral aspect of the fibula. The peroneal retinaculum is ruptured with an associated fleck of bone. On closer inspection, the peroneal groove is noted to be disrupted, rough, and shallow.

Figure 1  10-12 cm incision along the peroneal tendons.

The calcaneofibular ligament is intact and stable, and the posterior capsule gapped open. The ATFL is attenuated and the origin is slightly disrupted. The peroneal tendons are intact distally.

The damaged peroneal tendon are then tubularized using #2 fiber wire and placed back onto the fibular groove (Figs. 3,4). Subluxation and popping of the tendon is still noted. Because of this a reconstruction using the lateral 20% of the Achilles tendon is performed. A transverse incision is made into the Achilles tendon approximately 8 cm proximal to the insertion. The tendon is split distally and dissected through blunt means and used to protect the sural nerve and lateral structures. The low-lying muscle belly of the peroneus brevis, which is dissected away from the tendon just enough to pass the Achilles slip through its course. (Fig. 2) The cut end of the Achilles tendon is passed under the muscle belly of the peroneus brevis and over the peroneus longus and brevis tendons. (Figs. 5 and 6)

Figure 2  Resection of low lying muscle belly.

 

Figures 3 and 4 Repair of the peroneal tendons through tubularization.

 

Figures 5 and 6  A tunnel is made through the peroneus brevis muscle belly and the slip of the Achilles tendon is then passed over the peroneal tendons.

This bridge of tendon over the peroneal tendons is then anchored to the lateral malleolus using an Arthrex® bioabsorbable anchor. (Figs. 7,8 and 9) At completion of this reconstruction, there is no sign of subluxation of the peroneal tendons.

The wound is then irrigated and a modified Brostrom technique is used to repair and tighten the ligaments in a pants-over-vest fashion. This greatly increases the tension strength of the repair. The wound is then closed in layers.

  

Figures 7, 8 and 9  Bone anchor is used to anchor the repair.  The procedure is strengthened with a Modified Brostrom repair.

Discussion

There have been many options reported for surgical repair of peroneal subluxation or dislocation. These include direct repair of peroneal retinaculum, reconstruction of peroneal retinaculum, bone block (lateral malleolus, sliding graft), and groove deepening and rerouting procedures. [1,2,4,6,9]   Each of these procedures have their strengths and weaknesses. Acute repair of the superficial peroneal retinaculum is a simple repair however it may not be able to fix the underlying problem if there is a shallow grove, or the superior peroneal retinaculum itself is inherently weak due to prolonged inflammation. Reconstruction of the peroneal tendon can be accomplished using the peroneus brevis, plantaris, and/or Achilles tendons. There have been few studies reported on these techniques. A concomitant soft tissue procedure is a rerouting technique using the calcaneal fibular ligament. Bone block procedures incorporate part of an osteotomy used to deepen the fibular grove. This was first described by Kelly, and then modified by DuVries. [1,6,9,10] Complications associated with these techniques include graft fracture, tendonitis, pain and re-subluxation. Groove deepening procedures are performed by removing bone from the posterior aspect of the fibula. The result of deepening this grove is a more stable tunnel for the peroneus brevis and longus tendon sheath for gliding.

Peroneal tendon subluxation and dislocation is a condition which can be easily misdiagnosed as an ankle sprain and may cause a chronic painful condition requiring surgical intervention. As foot and ankle specialists we need to have a high suspicion, particularly in the younger athletic patients prone to such injuries.  The two most inherent causes of peroneal subluxation are multiple lateral ankle sprains and a shallow peroneal grove at the distal aspect of the tibia. Conservative treatment for this condition does not report a high success rate. The patient healed satisfactorily utilizing a lateral slip of the Achilles tendon in a tissue transfer technique and at the short term 6 month post op visit the patient had no complaints of pain.

References

1. Butler BW, Lanthier J, Wertheimer SJ: Subluxing peroneals: A review of the literature and case report. J Foot Ankle Surg 32: (2):134 – 139, 1993.
2 Oliva F, Ferran N, Maffulli N: Peroneal retinaculoplasty with anchors for peroneal tendon subluxation. Bull Hosp Joint Disease 63: (3 – 4): 113 – 116, 2006.
3. Ferran NA, Maffulli N, Oliva F: Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clinics 11: (3) 465 – 474, 2006.
4. Kollias SL, Ferkel RD: Fibular grooving for recurrent peroneal tendon subluxation. Am J Sports Medicine 25: (3):329 – 335, 1996.
5. Brage ME, Hansen ST Jr: Traumatic subluxation/dislocation of the peroneal tendons. Foot Ankle Online 13: (7): 423 – 431, 1992.
6. Tan V, Lin SS, Okereke E: Superior peroneal retinaculoplasty: a surgical technique for peroneal subluxation. Clinical Ortho Rel Res [serial online] 410: 320 – 325, 2003.
7. Krause JO, Brodsky JW: peroneus brevis tendon tears: Pathophysiology, surgical reconstruction, and clinical results. Foot Ankle Int 19: (5): 271 – 279, 1998.
8. Ferran NA, Maffulli N, Oliva F: Management of recurrent subluxation of the peroneal tendons. Foot Ankle Clinics [serial online]11: (3):465 – 474, 2006.
9. Niemi WJ, Savidakis J Jr, DeJesus JM: Peroneal subluxation: a comprehensive review of the literature with case presentations. J Foot Ankle Surg 36: (2): 141 – 145, 1997.
10. Porter D, McCarroll J, Knapp E, Torma J: Peroneal tendon subluxation in athletes: fibular groove deepening and retinacular reconstruction. Foot Ankle Int 26: (6): 436 – 441, 2005.
11. Heckman DS, Reddy S, Pedowitz D, Wapner KL, Parekh SG: Operative treatment for peroneal tendon disorders. J Bone Joint Surg 90A: (2): 404 – 418, 2008.
12. Mendicino RW, Orsini RC, Whitman SE, Catanzariti AR: Fibular groove deepening for recurrent peroneal subluxation. J Foot Ankle Surg 40: (4):252 – 263, 2001.


Address correspondence to:Adam MacEvoy, DPM. PGY III, Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center. Podiatry Surgery . Cleveland Ohio 44106. (216) 791-3800 Ext 5891

1 Precision Orthopedics, 150 7th Ave, Chardon , Ohio 44024.
2 Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center
Podiatry Surgery. Cleveland, Ohio 44106.
3 PGY III, Department Of Veterans Affairs. Louis Stokes Cleveland Medical Center. Podiatry Surgery . Cleveland, Ohio 44106.

© The Foot and Ankle Online Journal, 2009

Sesamoid bone interposition in the interphalangeal joint after dislocation of the hallux: A case report

by B. de Hartog, MD1 , P.F. Doorn MD, PhD2 , P.C. Rijk MD, PhD3  

The Foot and Ankle Online Journal 2 (7): 3

A 39 year-old woman injured the big toe of her right foot after a fall down the stairs. Upon examination there was a dislocation of the hallux. A plain radiograph showed a dislocation of the interphalangeal joint of the hallux and interposition of a sesamoid bone in the articular space. An attempt at closed reduction was unsuccessful, after which open reduction and excision of the sesamoid was undertaken. Dislocation of the interphalangeal joint of the hallux with interposition of a sesamoid is a rare injury. It is almost always the result of a hyperextension trauma. The clinical appearance together with a plain radiograph is in most cases sufficient for the diagnosis. Closed reduction should be attempted before open reduction is undertaken. If this is unsuccessful, it is probably due to an invaginated volar plate and sesamoid. Open reduction and removal of the sesamoid is then required followed by reduction of the volar plate plantarward. In general, the recovery is complete and without problems.

Keywords: Dislocation, hallux, interposition, sesamoids, treatment

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: June, 2009
Published: July, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0207.0003


A dislocation of the hallux with interposition of the sesamoid bone is a rare injury. [1,2,3,4,5,6] The treatment can consist of a closed reduction or an open repair. We report a 39 year-old woman with a painful hallux after a fall down the stairs. On the initial radiographs interposition in the interphalangeal joint (IPJ) of a sesamoid bone was seen. An attempt at closed reduction was unsuccessful after which the patient was treated with open reduction and excision of the sesamoid.

Case Report

A 39 year-old woman injured her right hallux after a fall down the stairs. She presented at the emergency room with an abnormal configuration of the hallux and in a significant amount of pain. On physical examination there was a dorsal dislocation of the IPJ of the great toe. Marked swelling and tenderness of the hallux was also noted.

Passive movement of the toe was very painful, active movement was not possible. The neurovascular status of the hallux was normal. A plain radiograph of the hallux showed a dislocation of the IPJ of the hallux and an entrapment of a sesamoid bone in the interphalangeal space (Figs. 1A and 1B). After local anaesthesia an attempt at closed reduction was undertaken, but was unsuccessful.

 

Figure 1A and 1B  Radiograph of the right hallux showing the enlarged joint space with the entrapment of the sesamoid in the interphalangeal space. (A) anteroposterior view. Lateral view of the interphalangeal joint. (B)

Following this, surgical removal of the sesamoid and reduction of the hallux was undertaken. Under general anaesthesia, a dorsal S-type incision was made over the IPJ. The extensor tendon was incised longitudinally and the joint capsule was opened. The sesamoid together with the volar plate were found within the articular space. The sesamoid was removed and the volar plate was reduced from the IPJ after which the hallux could be reduced. The joint capsule was closed and the skin was approximated. The patient was treated with 2 days compression bandage and normal mobilisation. The follow up was uneventful and the recovery was complete.

Discussion

Sesamoid bones of the hallux develop in the fetal period and aid the biomechanics of joint function. [7] The prevalence of interphalangeal sesamoids is approximately 13%. [8] The hallux can have one or two interphalangeal sesamoids. They are integrated in the plantar plate, which consist of the flexor hallucis longus tendon and the plantar joint capsule. [1,4,8] Dislocation of the IPJ with entrapment of a sesamoid is a rare injury and has not often been described in the literature. [1,2,3,4] This is partly due to tough soft tissue structures, which prevent hyperextension of the toe. Only when the collateral ligaments, the capsule and the volar plate are injured a dislocation of the IPJ is possible. [5] Often a hyperextension or an acute axial load type injury precedes an IPJ dislocation. [4,9] Muller described this type of injury for the first time in the Lancet in 1944. [10] At first presentation there is often tenderness of the hallux with inability of active movement. Physical examination involves palpation of the hallux, metatarsal phalangeal joint and sesamoid complex. A plain anteroposterior radiograph of the hallux is in most cases sufficient for the diagnosis. A widened interphalangeal space and interposition of a sesamoid has been observed. In some cases an overlapping of the two phalangeal bones with narrowing of the interphalangeal space can be seen. On the other hand, it has to be recognised that an epiphysial injury in adolescents can mimic a sesamoid dislocation. [2] Treatment can consist of closed reduction or surgical treatment. [2,8,11] Closed reduction, which has been successful in some cases, should be attempted by giving longitudinal traction, dorsal flexion follow by fast flexion in the IPJ. However, in several case reports it has been demonstrated that closed reduction is not successful. In these cases open reduction and reflexion or removal of the interphalangeal sesamoid and/or volar plate plantarward is mandatory. Although removal might have a negative effect on the biomechanics of the hallux, in most cases a complete recovery is made. [8]

References

1. Eibel P: Dislocation of the interphalangeal joint of the big toe with interposition of a sesamoid bone. J Bone Joint Surg 36A (4): 880 – 882, 1954.
2. Dave D, Jayaraj VP, James SE: Intra-articular sesamoid dislocation of the interphalangeal joint of the great toe. Injury 24 (3): 198 – 199, 1993
3. Berger JL, LeGeyt MT, Ghobadi R: Incarcerated subhallucal sesamoid of the great toe: Irreducible dislocation of the great toe by an accessory sesamoid bone. Am J Orthop 26: 116 – 228, 1997.
4. Sorene E.D, Regev G: Complex dislocation with double sesamoid entrapment of the interphalangeal joint of the hallux. Foot Ankle Surg 46 (6): 413 – 416, 2006.
5. Miki T, Yamamuro T, Kitai T: An irreducible dislocation of the great toe. Report of two cases and review of the literature. Clin Orthop Relat Res 230 : 200 – 206, 1988
6. Kursunuglu S, Resnick D, Goergen T: Traumatic dislocation with sesamoid entrapment in the interphalangeal joint of the great toe. J Trauma 27 : 959 – 961, 1987.
7. Rodeo SA, Warren RF, O’Brien SJ, Pavlov H: Diastasis of bipartite sesamoids of the first metatarsal phalangeal joint. Foot Ankle 14: 425 – 434, 1993.
8. Davies MB Abdlslam K, Gibson RJ: Interphalangeal sesamoid bones of the great toe: An anatomic variant demanding careful scrutiny on radiographs. Clinical anatomy 16: 520 – 521, 2003.
9. Nelson TL, Uggen W: Irreducible dorsal dislocation of the interphalangeal joint of the great toe. Clin Orthop Relat Res 157: 110 – 112, 1981.
10. Müller G.M: Dislocation of sesamoid of Hallux. Lancet 1: 789, 1944.
11. Szucs R, Hurwitz J: Traumatic subluxation of the interphalangeal joint of the hallux with interposition of the sesamoid bone. Am J Roentgenol 152 : 652 – 653, 1989.


Address correspondence to: P.C. Rijk, P.O. Box 888, 8901 BR Leeuwarden, The Netherlands, Tel: 0031-582867282, Fax: 0031-582867611
Email: P.Rijk@znb.nl

1 ,2,3  Bas de Hartog M.D, Peter F. Doorn M.D, PhD, Paul C. Rijk M.D, PhD
Department of Orthopaedic Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.

© The Foot and Ankle Online Journal, 2009

Rigid Stabilization of Partial Incongruous Lisfranc Dislocations: A Cannulated Solid Screw Technique

by Dane K. Wukich, MD1 , Dekarlos M. Dial, DPM2

The Foot and Ankle Online Journal 2 (6): 4

For several years, there has been much controversy over the optimal form of fixation in the operative treatment of Lisfranc injuries. Both cortical and cannulated screws have been widely used in the treatment of these injuries. The level of technical difficulty and reproducible accuracy of the cannulated screw system has gained much popularity. In comparison, the rigid stability of cortical screws appears more favorable. The authors present a cannulated technique utilizing a single 4.0 mm cortical screw (Synthes USA Paoli, Pa.). In Lisfranc injuries with partial incongruity, this method allows precise screw placement while maintaining rigid solid screw stabilization. The technique is minimally invasive, provides anatomical restoration and allows early return to functional activity.

Key Words: Lisfranc injury, midfoot fracture, cannulated screw, foot sprain, dislocation.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: May, 2009
Published: June, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0206.0004


Lisfranc fracture dislocations account for 0.2 % of all fractures.[1,2] In 1909, Quenu and Kuss described the first classification system for Lisfranc injuries. [3] This classification system was modified by Hardcastle in 1982. [2] In 1986, Myerson, et al., [5] further modified the Hardcastle classification into medial and lateral dislocations. Type A is a total incongruent tarsometatarsal joint complex. Types B1 is a partial incongruity with medical displacement affecting the first ray or first metatarsal, and B2 is partial incongruity resulting in lateral displacement of one or more lesser metatarsals. The most common Lisfranc injury in the athlete is the partial incongruous injury resulting in medial or lateral dislocation. [4,17,18,19]

Types C1 and C2 injuries result in partial or total displacement respectfully. Such classification systems allow communication between surgeons, but offer no prognostic value.

Stable anatomic reduction and internal fixation for Lisfranc fracture dislocations has been described using both screw and Kirchner wire fixation. Pin migration, infection and loss of reduction have been reported with Kirchner wire fixation. [11] Over the years, screw fixation has emerged as the superior fixation method for stabilizing the medial three tarsometatarsal joints. [1,6,7,8,9,10] Some disadvantages of screw fixation include articular cartilage damage and screw breakage. [12]

The authors share their surgical technique for addressing partial incongruous Lisfranc injuries; lateral displacement injuries affecting only the second metatarsal.

The technique is also useful for patients with a symptomatic subtle diastasis. This technique allows direct visualization of the injury, anatomical reduction, articular cartilage preservation, and rigid solid screw stabilization. The technique is avoided in patients with neuropathic arthropathy, peripheral vascular disease, insensate feet, open physis, complex dislocations, and open fracture dislocations.

Surgical Technique

Patients with partially incongruent Lisfranc injuries (B2) were treated with internal fixation utilizing 4.0 mm solid screw (Synthes®, Paoli, Pa. USA).

Pre-operatively, all patients receive a regional popliteal and femoral block. With the patient lying supine, a stress abduction stress is applied to the midfoot as described by Coss, et al.13 Stress radiography may obviate the need for stabilization of the entire tarsometatarsal joint complex. (Figs. 1 and 2)

Figure 1 Bilateral comparison weightbearing anteroposterior radiographs demonstrating partial incongruity of the second tarsometatarsal joint. Note the arrow identifying the first and second metatarsal base diastasis.

Figure 2  Oblique foot radiograph. Note the collinear relationship at the adjacent tarsometatarsal joints.

The neurovascular bundle is identified by palpating the dorsalis pedis artery prior to inflation of the calf tourniquet. The interval between the first and second metatarsal bases is verified under fluoroscopy. (Fig. 3) A single 6cm longitudinal skin incision is made medial to the neurovascular bundle.

Figure 3 Freer elevator used prior to guide incision placement to identify the interval between the first and second metatarsal cuneiforms.

Blunt dissection is continued down to the level of the extensor hallucis brevis muscle tendon (EHB). The EHB tendon is retracted laterally.

Subperiosteal dissection at the intercuneiform level is extended just distal to the first and second metatarsal base articulation. The Lisfranc ligament integrity is evaluated. A ruptured Lisfranc ligament, fibrotic tissue and or bone fragments can impede anatomical reduction and must be debrided and or excised. Care is taken to protect the neurovascular bundle and deep plantar artery.

Reduction is performed by placing a bone tenaculum around the medial cuneiform and second metatarsal base. The second metatarsal is reduced to the medial border of the middle cuneiform. The reduction is verified under fluoroscopy. (Fig. 4) If a diastasis remains present, first and second metatarsal base interval is inspected and the bone reduction tenaculum is adjusted. Once reduction of the diastasis is achieved, a 1.2 mm guide wire is obtained from the cannulated 3.5/4.0mm Synthes screw set.

Figure 4  A bone tenaculum is utilized to reduce the first and second metatarsal base diastasis.

The 1.2 mm guide wire is placed obliquely from the medial cuneiform (plantar proximal) into the second metatarsal base (distal dorsal) penetrating the lateral cortex. (Fig. 5)

Figure 5  The 1.2 mm guide wire is placed from medial to lateral just penetrating the second metatarsal base lateral cortex.

The knee is then flexed and the guide wire position is verified under fluoroscopy on both an anteroposterior and lateral projection. The medial cuneiform is then countersunk to prevent screw irritation. Next, the cannulated depth gauge is used to determine the screw length. The 1.2mm guide wire is advanced until it exits the foot dorsolaterally. (Fig. 6A and 6B).

 

Figures 6A and 6B The 1.2 mm guide wire is advanced obliquely until exiting the foot laterally allowing retrieval if breakage occurs. (A)  Note the direction of the guide wire in both the transverse and sagittal planes. (B)

By exiting the foot in this fashion, it allows easy retrieval of the guide wire if breakage occurs. The cannulated 2.5 mm drill bit is utilized to drill over the guide wire and penetrates the lateral second metatarsal base cortex. (Fig. 7) The appropriate length 4.0 mm screw is obtained and inserted in line with the guide wire. (Fig. 8A and 8B) To prevent toggle or misdirection during insertion, the guide wire is removed simultaneously.

Figure 7 The 2.5 mm cannulated drill is used to drill over the 1.2mm guide wire penetrating the lateral 2nd metatarsal base cortex.

 

Figures 8A and 8B 4.0 mm cortical screw (Synthes® Paoli, Pa. USA) (A)  Simultaneous placement of the 4.0mm solid screw and removal of the 1.2mm guide wire. (B)

The bone reduction tenaculum is disengaged and removed. Screw placement and stability are verified under fluoroscopy. (Fig. 9) The calf tourniquet is deflated and hemostasis achieved prior to closure.

Figure 9 Intraoperative anteroposterior image demonstrating diastasis reduction and 4.0mm solid screw fixation.

Postoperatively, patients are placed into a Jones compression dressing with a posterior splint for until postoperative day seven. The patient is then transferred into a short leg non-weightbearing cast for 14 days. At day 21 the sutures are removed and another short leg cast is applied. Patients are non-weightbearing for a further 6 weeks, followed by protected weight bearing in a walking boot with progression to normal shoe gear as tolerated.

Discussion

The standard treatment for Lisfranc joint injuries is to achieve anatomic reduction with internal fixation. Stable anatomical reduction results in more favorable long-term outcomes. [4,7,14] Buzzard, et al., reported that optimal results are obtained if precise anatomical reduction is achieved.1 Kuo, et al., reported that stable anatomic reduction lead to better long-term outcomes with higher AOFAS midfoot scores. [7]

Current recommendations support screw fixation in treatment of Lisfranc injuries. However, screw fixation is not without complications. Some authors believe that screw fixation results in articular cartilage damage during and that there is added risk for screw breakage. [15] Our technique preserves cartilage congruity and provides stabilization until ligamentous healing is restored. Thodarson, et al., found that absorbable screw fixation (PLA screws) was safe and eliminated the need for removal. [5]

In a cadaveric study, dorsal plating versus screw fixation showed no difference in resisting tarsometatarsal joint displacement. [15]

Ly, et al., recommended primary stable arthrodesis of purely ligamentous Lisfranc dislocations. The authors reviewed 41 patients with an average follow-up of 42 months. The average post-operative AOFAS score was 68.6 points in the open reduction and internal fixation group and 88 points for the arthrodesis group. The authors believe that stable arthrodesis prevented loss of correction and degenerative changes. [16]

The cannulated solid screw technique is an alternative treatment option for partial incongruous injuries or subtle dislocations. Excessive fixation is avoided while preserving articular congruity. The rigidity of the 4.0 mm solid screw allows early functional rehabilitation. Retrospectively, the authors have treated 10 patients using this technique with a zero incidence of hardware fatigue or breakage.

In conclusion, our technique has proven to be effective for stabilizing partial incongruous Lisfranc injuries. The technique is reproducible, accurate and allows for early function rehabilitation. The rigidity of the 4.0 mm solid screw provides optimal stability. However, care must be taken to individualize this treatment based on the extent of tarsometatarsal joint displacement.

References

1. Buzzard BM, Manos, RE, Buoncristiani A, Mills WJ: Surgical management of acute tarsometatarsal fracture dislocation in the adult. Clin Orthop 353: 125 – 133, 1998.
2. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W: Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone and Joint Surg 64B (3): 349 – 356, 1982.
3. Quenu E, Kuss G: Etude sur les luxations du metatarse (luxations metatarso-tariennes). Rev Chir 39: 281 – 336, 1909.
4. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle Clinics 6: 225 – 242, 1986.
5. Thodarson DB, Hurwitz G: PLA screw fixation of Lisfranc Injuries. Foot Ankle Int 23: 1003 – 1007, 2002.
6. Myerson MS: The diagnosis and treatment of injury to the tarsometatarsal joint complex. J Bone Joint Surg 81B: 756 – 763, 1999.
7. Kuo R, Tejwani N, DiGiovanni CW, Holt SK, Benirschke SK, Hansen ST Jr, Sangeorzan BJ: Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg 82A: 1609 – 1618, 2000.
8. Arntz CT, Hansen ST: Dislocations and fracture dislocations of the tarsometatarsal joints. Orthop Clin North Am 18: 105 – 114, 1987.
9. Bloome DM, Clanton TO: Treatment of Lisfranc injuries in the athlete. Tech. Foot Ankle Surg 1: 94 – 101, 2002.
10. Chiodo C, Myerson M: Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin North Am 32: 11 – 20, 2001.
11. Arntz CJ, Veith RG, Hansen Jr. ST: Fractures and fracture dislocations of the tarsometatarsal joints. J Bone Joint Surg 70A (2): 173 – 181, 1988.
12. Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ: Ligamentous Lisfranc joint injuries: A biomechanical comparison of dorsal plate and transarticular Screw Fixation. Foot Ankle Int 26: 462 – 473, 2005.
13. Coss HS, Manos RE, Buoncristiani A, Mills W: Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int 19: 537 – 541, 1998.
14. Goosens M, De Stoop N: Lisfranc’s fracture-dislocations: etiology, radiology, and results of treatment. Clin Orthop 176: 165 – 162, 1983.
15. Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ: Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. 26: 462 – 472, 2005.
16. Ly V, Coetzee JC: Treatment of primary ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg 88A: 514 – 520, 2006.
17. Davies MS, Saxby TS: Intercuneiform instability and the “gap sign”. Foot Ankle Int 20: 606 – 609, 1999.
18. Meyer SA, Callaghan JJ, Albright JP, Crowley ET, Powell JW: Midfoot sprains in collegiate football players. Am J Sports Medicine 22: 392-401, 1994.
19. Shapiro MS, Wascher DC, Finerman GA: Rupture of Lisfranc’s ligament in athletes. Am J Sports Med 22: 687 – 691, 1994.


Address correspondence to: Dekarlos M. Dial, DPM, Cornerstone Foot and Ankle Specialists, 1814 West Chester Drive, Suite 300, High Point, North Carolina 27262

Chief, Foot and Ankle Division, Department of Orthopaedic Surgery; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
3rd year resident, Department of Graduate Medical Education; University of Pittsburgh Medical Center Surgery, Pittsburgh, Pennsylvania.

© The Foot and Ankle Online Journal, 2009