Lisfranc fractures - when is the most appropriate time to remove the fixation?
Most foot and ankle surgeons will agree that there’s a need to remove fixation, particularly screw fixation, prior to failure of the fixation by weight-bearing. Once broken, internal fixation is almost impossible to remove without significant dissection.
So that begs the question; when is the best time to remove fixation? When a doctor has a question like this, there’s only one place to turn – to the literature.
A great 2010 International Orthopedics article, entitled ‘The role of reduction and internal fixation of Lisfranc fracture–dislocations: a systematic review of the literature’, does a good drill down on the topic by using a meta-analysis of the literature. (1) Here’s a summary of the article and aggregated recommendations from the articles reviewed.
- Routine hardware removal at 8, 10 or 12 weeks. (2,3,4,5)
- Routine hardware only after radiographic confirmation of healing. (6,7)
- Removal of hardware only if there’s hardware failure. (8,9)
- No recommendations for hardware removal (10,11,12)
What about removal by type of fixation (screw vs k-wire)? Screw removal was performed at 8 weeks in 14% of patients (4,5), 12 weeks in 11.6% of patients (2,3) and at 16 weeks in 17% of patients.(3,7) Clearly, no defined time limit here on removal of screw fixation for Lisfranc fractures. K-wires were typically removed at 6-8 weeks. (5,8)
Why the discrepancies in these numbers? Why doesn’t all fixation come out at the same time? First, you need to assess the patient in terms of the capacity to heal. Issues that may influence bone healing may include;
- Patient age
- History of smoking
- Ability to remain non-weight bearing
- Co-morbidities such as diabetes, renal disease
- Peripheral arterial disease
Specific to the injury itself, variation in fixation removal times may be due to;
- The fracture/dislocation pattern (Myerson, Hardcastle or Quénu and Küss classifications)
- True dislocation, fracture or combined fracture/dislocation
Yet, even after considering the make-up of the patient, co-morbidities and fracture/dislocation patterns, there’s still a significant range of answers to the simple question; when do you remove fixation in cases of Lisfranc’s fracture.
So if medicine is a science, why isn't there one answer to this question? Another case of ‘the art of medicine’ giving me job security.
- Stavlas, P, Roberts, C, et al. The role of reduction and fixation in Lisfrac fracture-dislocations: a systematic review of the literature. Int Orthop. 2010 Dec; 34(8): 1083–1091.
- Henning JA, Jones CB, Sietsema DL, et al. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009;30:913–922. doi: 10.3113/FAI.2009.0913.
- Mulier T, Reynders P, Dereymaeker G, et al. Severe Lisfrancs injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002;23:902–905.
- Rajapakse B, Edwards A, Hong T. A single surgeon's experience of treatment of Lisfranc joint injuries. Injury.2006;37:914–921. doi: 10.1016/j.injury.2005.12.003.
- Rammelt S, Schneiders W, Schikore H, et al. Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. J Bone Joint Surg Br.2008;90:1499–1506. doi: 10.1302/0301-620X.90B11.20695.
- Arntz CT, Veith RG, Hansen ST., Jr Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70:173–181.
- Teng AL, Pinzur MS, Lomasney L, et al. Functional outcome following anatomic restoration of tarsal-metatarsal fracture dislocation. Foot Ankle Int. 2002;23:922–926.
- Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82-A:1609–1618.
- 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;88:514–520. doi: 10.2106/JBJS.E.00228.
- Perez Blanco R, Rodriguez Merchan C, Canosa Sevillano R, et al. Tarsometatarsal fractures and dislocations.J Orthop Trauma. 1988;2:188–194. doi: 10.1097/00005131-198802030-00003.
- Perugia D, Basile A, Battaglia A, et al. Fracture dislocations of Lisfranc's joint treated with closed reduction and percutaneous fixation. Int Orthop. 2003;27:30–35.
- Tan YH, Chin TW, Mitra AK, et al. Tarsometatarsal (Lisfranc's) injuries—results of open reduction and internal fixation. Ann Acad Med Singapore. 1995;24:816–819.