Chinese Journal of Traumatology 18 (2015) 18e20

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Chinese Journal of Traumatology

journal homepage: http://www.elsevier.com/locate/CJTEE

Original article

Efficacy of open reduction and internal fixation with a miniplate and hollow screw
in the treatment of Lisfranc injury
Baoliang Li 1, Wenbo Zhao 1, Lei Liu*, Fuguo Huang, Guanglin Wang, Yue Fang
Department of Orthopedics, West China Hospital, Chengdu 610041, China

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: To investigate efficacy of open reduction and internal fixation with the miniplate and hollow
Received 5 July 2014 screw in the treatment of Lisfranc injury.
Received in revised form Methods: Ten cases of Lisfranc injury treated by open reduction, miniplate and hollow screw in our
22 August 2014
hospital were retrospectively analyzed. There were 6 males and 4 females with age ranging from 25 to 45
Accepted 26 August 2014
Available online 5 May 2015
years (mean 32 years). Among them, one case was classified as Type A, six Type B and three Type C.
Injury mechanism included road traffic accidents (3 cases), fall from height (5 cases) and hit by heavy
object (2 cases). All injuries were closed without cerebral trauma or other complicated injuries. The time
Keywords:
Lisfranc injury
interval between injury and operation was 6e10 days (average 6.6 days). Postoperatively, the foot
Open reduction and internal fixation function was assessed using Visual Analogue Scales (VAS) and American Orthopaedic Foot and Ankle
Miniplates Society (AOFAS) Scales. Healing time and complications were observed.
Screws Results: All patients were followed up for 18e24 months (average 20 months). Anatomic reduction was
achieved in all patients on images. There was statistical significance between preoperative score
(7.89 ± 0.34) and score at postoperative 8 weeks (0.67 ± 0.13). According to the AOFAS score, 5 cases were
defined as excellent, 3 cases as good and 2 cases as fair. During follow-up, there was no wound infection
or complications except for osteoarthritis in 2 cases. Healing time ranged from 3 to 6 months with an
average of 3.6 months.
Conclusion: Anatomical reduction of Lisfranc injury can be achieved by open reduction and internal
fixation with the miniplate and hollow screw. Normal structure of Lisfranc joint is regained to a great
extent; injured ligaments were also repaired. Therefore, this method offers excellent curative effect and
can avoid postoperative complications and improve the patients' quality of life.
© 2015 Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of
Surgery of the Third Military Medical University. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction inappropriate treatment of Lisfranc injuries can easily lead to a

With the fast development of society and economies, the inci-
dence of Lisfranc injuries has increased rapidly.1 The Lisfranc joint is
a complex multi-joint system, composed of bone joints, ligaments,
tendons and muscles to form the transverse and longitudinal
arches of the foot.2 Due to the characteristics of complex anatomic
structure and being easily masked by other severe combined in-
juries, the misdiagnosis rate is as high as 20%, which has been a
difficult problem for orthopedics surgeons.3 In addition, the
decline and even loss of foot function.4 Prompt diagnosis and
treatment is essential for Lisfranc injuries. This retrospective study
investigated 10 such cases treated by open reduction and internal
fixation, using the miniplate and hollow screw, from March 2013 to
March 2014 in our hospital. All cases achieved good results.
2. Material and methods
2.1. Patients' data

Among 10 cases of Lisfranc injuries, 1 was classified as Type A, 6

* Corresponding author. Tel.: þ86 18980602033.
Type B and 3 Type C. There were 6 males and 4 females with ages
E-mail address: Liuinsistence@163.com
Peer review under responsibility of Daping Hospital and the Research Institute
ranging 25e45 years (average 32 years). Injury mechanism
of Surgery of the Third Military Medical University. included road traffic accidents (3 cases), fall from height (5 cases)
1
Li BL and Zhao WB equally contributed to the paper. and hit by heavy object (2 cases). All injuries were closed without

http://dx.doi.org/10.1016/j.cjtee.2014.08.002
1008-1275/© 2015 Production and hosting by Elsevier B.V. on behalf of Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. This is
an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 BL. Li et al. / Chinese Journal of Traumatology 18 (2015) 18e20
any cerebral trauma or other complicated injuries. The time interval
between injury and operation was 6e10 days (average 6.6 days).
According to the AOFAS score, 2 patients were defined as good, 1
fair and 7 poor.
2.2. Surgical treatment
Discutientia was applied preoperatively. Application of ice
packs, elevation of the affected limb and other methods were
adopted to reduce soft tissue edema of the foot. Antalgesic fluid was
infused as routine, and vital signs were stable with blood pressure
below 160/100 mmHg and blood glucose below 8 mmol/L.
After general anesthesia, the patients were in the supine posi-
tion and tourniquet was wrapped around the root of the affected
thigh at a cuff pressure of 260 mmHg. After routine disinfection and
draping, a 5 cm longitudinal incision started between the first and
second intermetatarsals, and centered on the tarsometatarsal joint.
The skin, fascia and muscular tissue were separated. Extensor
retinaculum was exposed and excised to expose extensor pollicis
longus muscle tendon, dorsal artery. Lateral traction was done on
deep peroneal nerve. After the exposure of the first and second
tarsometatarsal joints, blood clots and bone fragments in the joint
space were cleared. The second metatarsal and its corresponding
tarsometatarsal joint were repositioned, followed by the restora-
tion of the first metatarsal and its corresponding tarsometatarsal
joint. Then a 1.0 cm Kirschner wire was used for temporary fixation.
After satisfactory fracture reduction was achieved on C arm fluo-
roscopy, the first and second metatarsals as well as the tarsome-
tatarsal joints were fixed by miniplate and screws. The same
operation was adopted to fix the third and fourth tarsometatarsal
joints.
A 1.5 cm Kirschner wire was inserted into the base of the second
metatarsal from the medial cuneiform along the ligament of Lis-
franc. A hollow screw was inserted along the Kirschner wire. After
that, a 1.5 cm Kirschner wire was inserted in the direction from the
fifth metatarsal to cuboid. A second hollow screw was then inserted
along the Kirschner wire. When good results were achieved on C
arm fluoroscopy, the incisions were closed.
Postoperatively antibiotics were administered for one day to
prevent infection. The affected limb was raised and ice packs were
applied to reduce swellings. Active exercises were started imme-
diately postoperatively for affected foot joint and ankle joint. After
2 days, nonweight-bearing was allowed. If the results on radio-
graphs were satisfactory at postoperative 3 months, patients could
progress to partial weight-bearing, until walking normally.
2.3. Statistical analysis
Data were analyzed by SPSS13.0. VAS score. VAS score was
measured by Student's t-test, and data were expressed as
mean ± standard deviation. AOFAS score was measured by c2 test.
P < 0.05 was considered statistically significant.
3. Results
All patients were followed up for 12e18 months with an average
of 15.2 months and no patients were lost to follow-up. There was
statistical significance between preoperative VAS score
(7.89 ± 0.34) and VAS score at postoperative 8 weeks (0.67 ± 0.13,
t ¼ 4.256, P < 0.05). According to the AOFAS score at postoperatively
12 months, 5 patients were defined as excellent, 3 as good, 2 as fair.
Excellent and good rate was 80% which significantly increased
when compared with preoperative excellent and good rate of 20%
(X2 ¼ 6.15, P < 0.05). During follow-up period, no patients suffered
from wound infection; while foot osteoarthritis occurred in 2 cases.
19
Fig. 1. A 65-year-old female suffered Lisfranc injury of the left foot (type B) in a road
traffic accident. (a) Preoperative image. (b) Image at postoperatively 1 year showing
fracture union.
Healing time of fracture was 3e6 months with an average of 3.6
months. A typical case is shown in Fig. 1.
4. Discussion
The Lisfranc joint complex mainly connects the midfoot and
forefoot, including the first and second tarsometatarsal joints, tar-
sometatarsal joints and the second-through-fifth metatarsal ba-
ses.5 In recent years, with the development of society, the incidence
of Lisfranc injuries has significantly increased.6 This disease im-
poses a great physiological and mental burden on patients, so a
proper treatment is very important. Due to its complexity, the rate
of missed diagnosis is high. Related studies have shown that type B
is most easily missed, opposite to type C.7 Treatment of a Lisfranc
injury should be individualized and the best therapy is based on
injury mechanism and injury type.8 Some researchers think that
anatomical reduction should be reached in all Lisfranc injury pa-
tients, and stable internal fixation is the key.9 In addition, the early
diagnosis of Lisfranc injury is also very important. Delayed diag-
nosis may lead to biomechanical damage of the injured foot, and
even lead to disability in severe cases.10
For the past few decades the most common treatment for Lis-
franc injuries has been plaster external fixation and Kirschner
wire.11 These methods are simple to operate and cost-effective.
However the therapeutic efficacy is poor, and they are difficult to
reach and maintain anatomical reposition.12 They are also associ-
ated with a high incidence of postoperative complications and poor
functional recovery. Therefore, it is generally accepted that open
reduction and internal fixation with plates and screws is appro-
priate for the Lisfranc injury.13 Prompt surgery is important to
improve the prognosis, and delayed surgery may cause serious
complications such as necrosis.14 Some studies15 show that in some
Lisfranc injuries the swelling is not severe in the first 6 h after
injury, then gradually aggravates 8 h later, and reaches the peak at
3e4 days, and then subsides at 7 days. Therefore, some researchers
believe that operation should be performed within 6 h or after 7
days following the injury.16 If operation cannot be done within 6 h,
antioncotics should be administered and the affected limb should
be raised with application of ice. When swelling goes down, and
skin wrinkles appear, operation can be done.17
In addition to the proper operation time, surgical procedure is
also very important. We should pay attention to the following
points: 1) The screws pass through the double cortex as far as
possible, because eccentric single cortical fixation is not conducive
to maintaining the stability of the joints. Double cortex fixation
requires careful operation to avoid damage of the thenar vascular
20 BL. Li et al. / Chinese Journal of Traumatology 18 (2015) 18e20
nerve; 2) For limbs with severe soft tissue contusion, external fix-
ator can be used for maintaining normal shape of the joint at first.
After recovery of soft tissue, a second operation can be done. 3)
During the reconstruction of the Lisfranc ligament, the insertion of
the guide pin and countersunk screw should be achieved at first
attempt to avoid Lisfranc ligament damage caused by repeated
insertion. 4) Intraoperatively, extensor pollicis longus muscle
tendon, dorsal artery of foot, and deep peroneal nerve should be
mainly protected to avoid necrosis or numbness. Besides the above
mentioned points, therapeutic effect was influenced to a great
extent by whether ligament is injured and its integrity degree.
Lisfranc joint ligament can be divided into dorsal ligament, plantar
ligaments and interosseous ligament.18 Lisfranc ligament starts
from the plantar side of the medial cuneiform to second metatarsal
base. Some researchers have proven that the Lisfranc ligament has
the maximum width, thickness and cross-sectional area of all these
ligaments, so its ultimate load is far higher than the others.19
Reconstruction of the Lisfranc ligament is of great importance for
the function of the foot. At present, the Lisfranc ligament is most
commonly repaired by hollow countersunk screw inserted from the
medial cuneiform to the second metatarsal base. Our study also
adopted this method and achieved a satisfactory clinical effect.
After the surgery, functional exercises are paramount. Patients
should actively move foot joints and ankle joint to reduce compli-
cations and to maximize the recovery of foot function.
In our study, the open reduction with miniplate and hollow
screws was preformed on 10 patients with a Lisfranc injury, and
achieved a satisfactory clinical effect. The main advantages of this
method are as follows: 1) Bone fragments and soft tissue embedded
in joint space can be removed under direct vision, and the damaged
joint capsule and ligaments can be repaired; 2) Anatomical fracture
can be reduced with accurate placement of internal fixation device;
3) Miniplate occupies little space, which does not cause high
pressure within the foot; 4) Early postoperative activities for the
joint is advantageous to the foot function recovery; 5) The damage
of articular cartilage can be avoided and the incidence of traumatic
arthritis is reduced; 6) Lisfranc ligament repaired using hollow
screws is more consistent with principles of the current therapy. In
our study, foot osteoarthritis appeared in 2 cases at postoperatively
6 months, probably due to joint surface damage during guide pin or
screw placement. Related research confirmed that the occurrence
of postoperative foot osteoarthritis is closely related to articular
cartilage injuries, so protection of the cartilage surface can signifi-
cantly reduce the incidence of foot osteoarthritis.20 During the
operation, guide pins and screws should be inserted accurately
under fluoroscopy to reduce joint surface damage. Finally, stable
internal fixation of the fracture can maintain anatomic reduction
until the fracture heals. In some cases an injured ligament may
occur, but it is difficult to predict.21 Ligament rupture is often
repaired by scar tissue, which has poor tensile resistance as well as
wear resistance, and can easily cause ligament re-rupture and
makes the joint unstable.22 So our patients were treated with
hollow screws inserted from the medial cuneiform to the second
metatarsal bone base and another one inserted from the fifth
metatarsal base to the cuboid, to enhance the strength of the Lis-
franc ligament and to maintain the anatomical reduction.
There are some limitations in this study as well. Lisfranc injuries
are relatively rare, so our sample size is small. In addition, the in-
dividual damage condition varies, therefore the preoperative
baseline is not completely consistent. With further research of
Lisfranc injury anatomy, biomechanics and injury mechanism, the
missed diagnosis of Lisfranc injuries will be significantly lower in
the future. Along with the continuous improvement of various in-
ternal fixation devices, the effect of surgical treatment on Lisfranc
injury will be better. We believe that the future research trend is
individualized based on each patient's condition. Special attention
should be paid to postoperative function recovery, to provide better
diagnosis and treatment of Lisfranc injury patients.
References
1. Harrasser N, Gradl G. Mid-foot fractures of the chopart and lisfranc joint line.
MMW Fortschr Med. 2014;156:54e55.
2. O'Neill BJ, Sweeney LA, Moroney PJ, et al. Atypical stress-avulsion fracture of
the Lisfranc joint complex. Foot Ankle Spec. 2014;7:155e158.
 ska M, Gawe˛ da K, Dajewski Z, et al. Comparison of treatment results of
3. Tarczyn
acute and late injuries of the lisfranc joint. Acta Ortop Bras. 2013;21:344e3446.
4. Diebal AR, Westrick RB, Alitz C, et al. Lisfranc injury in a west point cadet. Sports
Health. 2013;5:281e285.
5. Gallagher SM, Rodriguez NA, Andersen CR, et al. Anatomic predisposition to
ligamentous Lisfranc injury: a matched case-control study. J Bone Jt Surg Am.
2013;95:2043e2047.
6. Hirano T, Niki H, Beppu M, et al. Anatomical considerations for reconstruction
of the Lisfranc ligament. J Orthop Sci. 2013;18:720e726.
7. Eleftheriou KI, Rosenfeld PF. Lisfranc injury in the athlete: evidence supporting
management from sprain to fracture dislocation. Foot Ankle Clin. 2013;18:
219e236.
8. Gotha HE, Lareau CR, Fellars TA, et al. Diagnosis and management of lisfranc
injuries and metatarsal fractures. R I Med J. 2013;96:33e36.
9. Schepers T, Oprel PP, Van Lieshout EM, et al. Influence of approach and implant
on reduction accuracy and stability in lisfranc fracture-dislocation at the tar-
sometatarsal joint. Foot Ankle Int. 2013;34:705e710.
10. Nazarenko A, Beltran LS, Bencardino JT. Imaging evaluation of traumatic liga-
mentous injuries of the ankle and foot. Radiol Clin North Am. 2013;51:455e478.
11. Garchar D, Didomenico LA, Klaue K, et al. Reconstruction of Lisfranc joint
dislocations secondary to charcot neuroarthropathy using a plantar plate. J Foot
Ankle Surg. 2013;52:295e297.
12. Eleftheriou KI, Rosenfeld PF, Calder JD. Lisfranc injuries: an update. Knee Surg
Sports Traumatol Arthrosec. 2013;21:1434e1446.
13. Pourcho AM, Liu YH, Milshteyn MA. Electrodiagnostically confirmed post-
traumatic neuropathy and associated clinical exam findings with lisfranc
injury. Foot Ankle Int. 2013;34:1068e1073.
14. Benirschke SK, Meinberg EG, Anderson SA, et al. Fractures and dislocations of
the midfoot: lisfranc and chopart injuries. Instr Course Lect. 2013;62:79e91.
15. Wagner E, Ortiz C, Villalo  n IE, et al. Early weight-bearing after percutaneous
reduction and screw fixation for low-energy lisfranc injury. Foot Ankle Int.
2013;34:978e983.
16. García-Renedo RJ, Carranza-Bencano A, Busta-Vallina B, et al. Long-term results
of the treatment of Lisfranc fracture dislocation. Acta Orthop Mex. 2012;26:
235e244.
17. Bandac RC, Botez P. Lisfranc midfoot dislocations: correlations between sur-
gical treatment and functional outcomes. Rev Med Chir Soc Med Nat Lasi.
2012;116:834e839.
18. Nery C, Re ssio C, Alloza JF, et al. Subtle Lisfranc joint ligament lesions: surgical
neoligamentplasty technique. Foot Ankle Clin. 2012;17:407e416.
19. Ghate SD, Sistla VM, Nemade V, et al. Screw and wire fixation for Lisfranc
fracture dislocations. J Orthop Surg (Hong Kong). 2012;20:170e175.
20. Sheibani-Rad S, Coetzee JC, Giveans MR, et al. Arthrodesis versus ORIF for
Lisfranc fractures. Orthopedics. 2012;35:e868e873.
21. Pelt CE, Bachus KN, Vance RE, et al. A biomechanical analysis of a tensioned
suture device in the fixation of the ligamentous Lisfranc injury. Foot Ankle Int.
2011;32:422e431.
22. Hart ES, Turner A. Lisfranc fracture-dislocations. Orthop Nurs. 2011;30:
213e214.