Mormino, MDAbstract Lisfranc described amputations through the tarsometatarsal TMT joint for the treatment of severe, gangrenous mid-foot injuries, and his name has been associated with
Trang 1Michael C Thompson, MD, and Matthew A Mormino, MD
Abstract
Lisfranc described amputations through
the tarsometatarsal (TMT) joint for the
treatment of severe, gangrenous
mid-foot injuries, and his name has been
associated with many different
inju-ries to this region.1Myerson2described
such injuries as involving the
tarsometa-tarsal complex (TMC), which includes
the metatarsals and TMT joints, the
cuneiforms, the cuboid, and the
na-vicular.2The spectrum of TMC injury
ranges from low-energy trauma, such
as a misstep, to high-energy crush
in-juries characterized by extensive
os-seous comminution and soft-tissue
com-promise Accordingly, the pattern of
TMC injury is highly variable and may
involve purely ligamentous
disrup-tions without fracture, associated
meta-tarsal fractures, or fractures of the
cu-neiforms, cuboid, or navicular
Accurate diagnosis of these
inju-ries is paramount Although only
min-imal displacement may be present on
initial radiographs, severe
ligamen-tous disruption might still exist Left
untreated, such disruption may result
in marked disability characterized by
painful posttraumatic arthritis and pla-novalgus deformity.3,4A high index
of suspicion should be maintained when examining a patient with an injured foot because delayed or missed diag-nosis occurs in up to 20% of cases.5-7 The goal of treating TMC injury is
to obtain a plantigrade, stable, pain-less foot Successful outcome largely
is related to obtaining and maintain-ing an anatomic reduction.5,6,8,9
Ear-ly studies documented the failure of closed reduction to maintain an an-atomic reduction.10-12In 1982, Hard-castle et al13reported that open tech-niques with temporary, nonrigid fixation occasionally resulted in late displacement Rigid screw fixation, the technique reported by Arntz et al6in
1988, has become the preferred
meth-od for stabilization of these injuries.5
Anatomy and Biomechanics
Understanding the anatomy of the TMC is imperative for accurate
assess-ment and treatassess-ment of injuries Sta-bility of the complex is achieved by
a combination of bony architecture and ligamentous support The medial, mid-dle, and lateral cuneiforms articulate distally with the first, second, and third metatarsals, respectively14(Fig 1, A) The cuboid articulates distally with the fourth and fifth metatarsals The middle cuneiform is recessed proxi-mally relative to the medial and lat-eral cuneiforms This mortise config-uration accommodates the base of the second metatarsal and lends additional osseous stability at this articulation
In the coronal plane, stability is fur-ther enhanced by the so-called Roman arch configuration of the metatarsal bases, with the second metatarsal base acting as the keystone (Fig 1, B) Ligaments supporting the TMC are grouped according to anatomic lo-cation (dorsal, plantar, and in-terosseous) The lesser metatarsals are bound together by dorsal and plan-tar intermetaplan-tarsal ligaments (Fig 1, A) Similarly, dorsal and plantar in-tertarsal ligaments hold the cunei-forms and cuboid together There are
Dr Thompson is Chief Resident, Department of Orthopaedic Surgery and Rehabilitation, Creighton-Nebraska Health Foundation, University of Ne-braska Medical Center, Omaha, NE Dr Mormino
is Assistant Professor and Director, Orthopaedic Trauma, Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center.
Reprint requests: Dr Mormino, 981080 Nebraska Medical Center, Omaha, NE 68198-1080 Copyright 2003 by the American Academy of Orthopaedic Surgeons.
Tarsometatarsal joint complex fracture-dislocations may result from direct or
in-direct trauma Direct injuries are usually the result of a crush and may involve
as-sociated compartment syndrome, significant soft-tissue injury, and open
fracture-dislocation Indirect injuries are often the result of an axial load to the plantarflexed
foot Midfoot pain after even a minor forefoot injury should raise suspicion; up to
20% of tarsometatarsal joint complex injuries are missed on initial examination.
An anteroposterior radiograph with abduction stress may reveal subtle injury, but
computed tomography is the preferred imaging modality The goal of treatment is
the restoration of a pain-free, functional foot The preferred treatment is open
re-duction and internal fixation, using screw fixation for the medial three rays and
Kirschner wires for the fourth and fifth tarsometatarsal joints Satisfactory outcome
can be expected in approximately 90% of patients.
J Am Acad Orthop Surg 2003;11:260-267
Trang 2no ligamentous connections between the first and second metatarsal bases
The largest and strongest interos-seous ligament in the TMC is the so-called Lisfranc ligament, which
aris-es from the lateral surface of the medial cuneiform and inserts onto the medial aspect of the second metatar-sal base near the plantar surface.14The first metatarsal base is anchored to the dorsal and plantar aspects of the me-dial cuneiform by two longitudinal ligaments The peroneus longus and tibialis anterior tendon insertions fur-ther stabilize the first TMT joint A variable network of longitudinal and oblique ligaments secures the remain-der of the metatarsals to the cunei-forms and cuboid on the dorsal and plantar aspects of the complex In general, the dorsal ligaments are weaker than their plantar counter-parts To a lesser extent, the plantar fascia and intrinsic musculature of the foot add stability to the TMC
Because of the unique bony and lig-amentous anatomy of the TMC, nor-mal motion of the individual compo-nents varies Having articular contact with all three cuneiforms, the base of the second metatarsal demonstrates very little motion under normal cir-cumstances, with an average dorsi-flexion-plantarflexion arc of 0.6°.15In comparison, dorsiflexion-plantarflexion
at the third TMT joint is approximately 1.6°, and, at the first joint, 3.5° The fourth and fifth TMT joints are the most mobile, demonstrating an average
of 9.6° and 10.2° of dorsiflexion-plantarflexion, respectively.15
Injury to the Tarsometatarsal Joint Complex
The overall annual incidence of TMC injuries is approximately 1 per 60,000 persons,13,16and the injury is two to three times more common in males (Table 1) Motor vehicle accidents are the most frequently cited mechanism, accounting for about 40% to 45% of injuries Low-energy mechanisms ac-count for approximately 30% Falls from a height and crush injuries are also commonly reported causes The mechanism of TMC injury may
be either direct or, more commonly, indirect trauma The direct mechanism involves high-energy blunt trauma, usually applied to the dorsum of the foot Crush injuries constitute most of these injuries, and many are associ-ated with notable soft-tissue trauma Associated compartment syndromes and open fracture-dislocations are more often present with direct
inju-ry mechanisms In part as a result of
Figure 1 A, Anteroposterior view of the
bony and ligamentous anatomy of
tarsometa-tarsal joint complex I through V =
metatar-sal bones (Adapted with permission from
Myerson MS: Fractures of the midfoot and
forefoot, in Myerson MS: Foot and Ankle
Dis-orders Philadelphia, PA: WB Saunders, 2000,
vol 2, pp 1265-1296.) B, Coronal section
through the metatarsal bases illustrating the
Roman arch configuration (Adapted with
permission from Lenczner EM, Waddell JP,
Graham JD: Tarsal-metatarsal [Lisfranc]
dis-location J Trauma 1974;14:1012-1020.)
Table 1
Tarsometatarsal Joint Complex: Mechanisms of Injury
No of Injuries (%) Study
No of Patients/
Injuries (M/F)
Motor Vehicle Accident
Fall From
Hardcastle et al13 119/119 (86/33) 48 (40.3) 16 (13.5) 0 (0) 55 (46.2)
NA = not available
Trang 3the associated soft-tissue trauma and
greater degree of articular injury,
di-rect injuries often result in a worse
clin-ical outcome compared with indirect
injuries.8,9
The indirect mechanism of injury
usually involves axial loading of the
plantarflexed foot An example is a
football player falling onto the heel
of another player whose foot is planted
and plantarflexed This type of injury
also can occur with soccer, basketball,
and gymnastics.17Falls from a height
may result in forefoot plantarflexion
at the time of impact In automobile
accidents, injury to the plantarflexed
foot occurs with a combination of
de-celeration and floorboard intrusion
Less commonly, violent abduction or
twisting of the forefoot may result in
fracture-dislocation around the TMC
The fracture pattern and direction
of dislocation in direct injuries are
highly variable and depend on the
force vector applied In contrast, the
most frequent pattern seen in indirect
injuries involves failure of the
weak-er dorsal TMT ligaments in tension,
with subsequent dorsal or
dorsolat-eral dislocation of the metatarsals
Mi-nor displacement at the TMT joint
level results in a marked reduction in
articular contact Dorsolateral
dis-placement of the second metatarsal
base of 1 or 2 mm results in the
re-duction of the TMT articular contact
area by 13.1% and 25.3%,
respective-ly.18Although fractures of the
cune-iforms are relatively common, the
most frequent fracture in TMC
inju-ries involves the second metatarsal
base.16Less common are associated
fractures of the cuboid, navicular, or
other metatarsals
Diagnosis
The diagnosis of high-energy or crush
injuries to the TMC is relatively
straightforward Examination
typical-ly reveals moderate to severe
swell-ing of the forefoot and, in open
inju-ries, disruption of the skin and
subcutaneous tissue Inspection of the foot may reveal gross morphologic ab-normalities such as widening or flat-tening A gap between the first and second toes is suggestive of intercu-neiform disruption as well as TMT joint injury.19,20Palpation of the dor-salis pedis artery may not be pos-sible, depending on the extent of swelling and deformity Although dis-ruption of the dorsalis pedis artery has been reported, the incidence of vas-cular injury appears to be rare.7,21,22 Significant pain on passive dorsiflex-ion of the toes in a tensely swollen foot
is suggestive of a compartment syn-drome; however, evaluation may be hampered by pain associated with the osseous injury.23,24When there is un-certainty about the presence of a com-partment syndrome, pressures should
be measured An absolute pressure >40
mm Hg is diagnostic and an indica-tion for emergent compartment re-lease Particularly in the hypotensive patient, a compartment pressure
with-in 30 mm Hg of the diastolic pressure also is an indication for release
Findings after a low-energy TMC injury may be relatively subtle Ahigh index of suspicion should be main-tained in the patient with forefoot
pain after even a minor traumatic event Patients usually have notable pain on weight bearing or are unable
to bear weight on the affected foot Swelling is present to a variable ex-tent, and ecchymosis occasionally is found along the plantar aspect of the midfoot.25 Palpation of the affected TMT joints usually reveals tender-ness Notable pain on passive abduc-tion and pronaabduc-tion of the forefoot also
is suggestive of TMC injury.17 The initial radiographic examina-tion should include anteroposterior, lateral, and 30° oblique views of the foot To visualize the Lisfranc joint in the tangential plane, the anteropos-terior radiograph should be taken with the beam approximately 15° off vertical Standing radiographs are ideal but may be difficult to obtain secondary to pain (Fig 2, A and B)
If weight-bearing views are not pos-sible, a stress view with the forefoot
in abduction often will reveal subtle instability, especially at the first TMT joint.17,26All radiographs should be evaluated for signs of instability On the anteroposterior view, the distance between the first and second metatar-sal bases varies among uninjured in-dividuals, with up to 3 mm
consid-Figure 2 A,Anteroposterior non–weight-bearing radiograph of a patient with forefoot pain after an axial load injury Note the subtle widening (arrow) between the bases of the first and
second metatarsals B, Anteroposterior standing view of the same patient as in Panel A dem-onstrating subluxation (arrow) at the base of the second metatarsal C, Anteroposterior view
of a patient with avulsion of the Lisfranc ligament, or fleck sign (arrow), at the base of the second metatarsal.
Trang 4ered normal.26,27 In subtle cases,
radiographs of the contralateral foot
should be obtained for comparison
Stein28reviewed 100 radiographs
of normal feet and noted several
con-stant anatomic relationships On the
anteroposterior view, the medial
bor-der of the second metatarsal is in line
with the medial border of the
mid-dle cuneiform, the first metatarsal
aligns with the medial and lateral
bor-ders of the medial cuneiform, and the
first and second intermetatarsal space
is continuous with the intertarsal space
of the medial and middle cuneiforms
(Fig 1, A) On the 30° oblique view,
the medial border of the fourth
meta-tarsal is in line with the medial
bor-der of the cuboid, the lateral borbor-der
of the third metatarsal is aligned with
the lateral border of the lateral
cune-iform, and the third and fourth
inter-metatarsal space is continuous with
the intertarsal space of the lateral
cu-neiform and the cuboid.28
Other radiographic findings may
assist with diagnosis The fleck sign,
or avulsion of Lisfranc’s ligament at
the base of the second metatarsal, is
diagnostic of TMC injury9(Fig 2, C)
Analysis of the medial column line on
an anteroposterior abduction stress
view may reveal subtle injury26(Fig
3) Flattening of the longitudinal arch
may suggest injury to the TMC and
can be evaluated by comparing the
weight-bearing lateral view to that of
the uninjured foot.29
Computed tomography (CT) has
proved to be a valuable tool in the
di-agnosis of injuries to the TMC It is
more sensitive than plain radiographs
in detecting minor displacement and
small fractures.30-32Displacement of
up to 2 mm may not be detectable on
plain radiographs but is visible on
CT.31Axial and coronal views of both
feet should be made for comparison
Subtle widening or dorsal
sublux-ation of the metatarsals are CT
find-ings suggestive of TMC disruptions,
and avulsion fracture of the second
metatarsal base is diagnostic of
in-jury33(Fig 4) In high-energy
fracture-dislocations, a preoperative CT may facilitate surgical planning by delin-eating the extent of osseous injury
The role of magnetic resonance im-aging (MRI) in evaluating TMC inju-ries has yet to be defined MRI is more sensitive than plain radiographs in detecting small fractures and joint malalignment and in assessing liga-mentous structures around the TMC.33,34However, with regard to di-agnosis and decision-making, CT is superior to MRI.30Therefore, MRI is not routinely recommended in the as-sessment of these injuries
Classification
The earliest classification system was published in 1909 by Quenu and Kuss12and subsequently modified by Hardcastle et al13in 1982 and Myer-son et al9in 1986 The most recently
published classification system, pub-lished by the Orthopaedic Trauma Association,35is similar to the orig-inal Quenu and Kuss classification These classification systems are all based on the congruency of the TMT joints and the direction of displace-ment of the metatarsal bases Com-mon to all classification systems is that none appears to be helpful in terms of management or prognosis.9
Management
Nonsurgical management of TMC in-juries should be limited to those that are without fracture, nondisplaced, and stable under radiographic stress examination As little as 2 mm of dis-placement or the presence of a frac-ture within the TMC warrants fixa-tion Nondisplaced, stable ligamentous injuries may be treated in a non–
Figure 3 Medial column line On an anteroposterior radiograph with the forefoot stressed
in abduction (dashed outline of first metatarsal), a line is drawn tangential to the medial bor-ders of the navicular and medial cuneiform (heavy dashed line) Failure of this line to
in-tersect the base of the first metatarsal is strongly suggestive of TMC injury A, Normal foot.
B,First, second, and third TMT joint disruption (heavy dark line) Arrows indicate direction
of forces (Adapted with permission from Coss HS, Manos RE, Buoncristiani A, Mills WJ: Abduction stress and AP weightbearing radiography of purely ligamentous injury in the
tar-sometatarsal joint Foot Ankle Int 1998;19:537-541.)
Trang 5weight-bearing short leg cast for a
minimum of 6 weeks Radiographic
examination should be done 1 to 2
weeks after injury to ensure that
align-ment and stability are maintained
Gradual weight bearing in a
protec-tive brace may begin at 6 weeks
Per-mission for unrestricted activity, such
as running and jumping, should be
withheld for 3 to 4 months
Although displaced or unstable
TMC injuries have been treated by
closed reduction and casting, loss of
reduction was common and outcomes
were variable, with a high incidence
of poor results Currently accepted
sur-gical techniques involve either closed
reduction with percutaneous
Kirsch-ner wire (K-wire) or screw fixation2
or open reduction with screw and/
or K-wire fixation.4-6For fixation of
the medial three TMT joints, screw
fix-ation may be preferable to K-wires
be-cause ligamentous healing may
re-quire as much as 12 to 16 weeks of
immobilization to occur, and K-wires
can become loose, necessitating
re-moval as early as 6 weeks
Regard-less of the technique used, the goal
should be anatomic reduction of the
affected joints because numerous
stud-ies have documented that clinical
out-come correlates with accuracy of
reduction.1,5-9,12,21,36,37
Ideally, surgical management of closed injuries is undertaken when soft-tissue swelling is at a minimum, either immediately or after swelling has abated This delay may take up
to 2 weeks and can be identified by the return of wrinkles to the skin The initial incision is made dorsally be-tween the first and second web space
The extensor hallucis longus tendon, deep peroneal nerve, and dorsalis pe-dis artery are identified and
retract-ed as a unit, allowing deep, sharp dis-section to expose the first and second TMT joints Small, irreducible bone fragments are débrided from the joints The reduction should begin medially and progress laterally
Aligning the medial aspect of the first metatarsal and the medial cuneiform reduces the first TMT joint The en-tire medial aspect of this joint is ex-posed to ensure that plantar gapping
is not present The reduction is pro-visionally held with a K-wire, and the joint is stabilized with a countersunk 3.5- or 2.7-mm screw placed from the base of the first metatarsal into the medial cuneiform Using fully
thread-ed cortical screws placthread-ed for position-ing, rather than compression, is pref-erable Screws crossing otherwise normal joints result in little, if any, long-term morbidity If rotational
in-stability of the first TMT joint persists after placement of the first screw, a second screw or K-wire may be placed from the medial cuneiform into the base of the first metatarsal The second metatarsal is then re-duced to the medial border of the middle cuneiform and temporarily held with a K-wire Definitive fixation follows with a 3.5- or 2.7-mm coun-tersunk screw directed from the base
of the second metatarsal into the mid-dle cuneiform A 3.5-mm screw is usually appropriate for most patients;
a 2.7-mm screw may be used for pa-tients of small stature or when there
is concern about the size of the
3.5-mm screw relative to the diameter of the second metatarsal Medial column fixation is then completed by placing
a 3.5- or 2.7-mm screw from the me-dial cuneiform into the base of the second metatarsal
If the third TMT joint is disrupted and remains unstable after fixation of the first and second TMT joints, a sec-ond dorsal incision is made between the third and fourth metatarsals to ex-pose the third TMT joint This joint
is similarly reduced and fixed with a 3.5- or 2.7-mm screw directed from the base of the third metatarsal into the lateral cuneiform Reduction of the fourth and fifth TMT joints usu-ally occurs with reduction of the me-dial three TMT joints and is secured with percutaneous K-wire fixation (Fig 5) Alternative fixation, although typically unnecessary, is done with screw fixation
Occasionally, an associated
impact-ed (nutcracker) fracture of the cuboid may require treatment The technique described by Sangeorzan and Swiont-kowski38involves restoration of cuboid length by distraction bone grafting and plating Failure to restore length re-sults in lateral column shortening and
a persistently abducted and pronated forefoot A distractor or external fix-ator may be used intraoperatively to facilitate distraction before plating (Fig 6) Associated fractures of the navicu-lar may be exposed and stabilized by
Figure 4 A,Coronal CT scan demonstrating subtle widening (arrow) of the first and
ond metatarsal bases B, Coronal CT scan showing an avulsion fracture (arrow) of the
sec-ond metatarsal base.
Trang 6extending the dorsal medial incision
proximally In most cases, fragments
are large enough to accommodate
3.5-or 2.7-mm screws placed using a lag
technique
Rarely, severely comminuted or
contaminated injuries of the TMC may
not be amenable to internal fixation
using standard techniques Temporary
or definitive spanning external
fixa-tion is an opfixa-tion for these difficult
cas-es Limited percutaneous fixation with
K-wires or screws may augment
sta-bilization but should be used with
cau-tion in contaminated cases
Wound closure should be
accom-plished with meticulous soft-tissue
handling and closure Ashort leg, non–
weight-bearing cast is maintained for
6 weeks Any percutaneous pins are
then removed, and the patient is
ad-vanced to full weight bearing in a
walking boot for an additional 4 to 6
weeks The indication for screw
re-moval remains controversial.2,5Most
authors recommend routine
remov-al of the screws either on weight
bear-ing or approximately 16 weeks after
fixation.2We prefer to remove screws
only if patients are symptomatic but
no sooner than 16 weeks
postopera-tively Broken screws seem to occur
in only a minority of patients Further- more,affectedpatientsareoftenasymp-tomatic, although broken screws may
be problematic if salvage by fusion is necessary
When a compartment syndrome is diagnosed at the initial evaluation, emer-gent fasciotomy should be done.23 Us-ing the two dorsal incisions described, the interosseous compartments are each released Dissection between the meta-tarsals is done to achieve release of the medial, central, and lateral com-partments (Fig 7) Rarely, associated hindfoot injuries such as a calcaneus fracture may be present and may re-quire release of the calcaneal compart-ment This may be achieved through
a longitudinal medial incision over the compartment After fasciotomy, defin-itive fixation should be done Fascial compartments and wounds should be left open, and the patient may undergo redébridement and attempted wound closure within 48 to 72 hours Delayed primary wound closure may not be possible, and coverage with split-thickness skin graft may be necessary.23,24 Open TMC fracture-dislocations should be treated as surgical emergen-cies Débridement and irrigation should
be done within 6 hours of injury, if possible In addition to tetanus pro-phylaxis, Gustilo and Anderson type
I and II open injuries should receive
a first-generation cephalosporin, with
an aminoglycoside added for type III injuries Severe contamination or vas-cular compromise requires adding pen-icillin G to the antibiotic regimen
Wounds are left open and covered with saline gauze or an equivalent dress-ing Repeat débridement and irriga-tion are done every 48 hours until a clean, viable wound bed is achieved
Ideally, wound closure is achieved by delayed primary closure In the foot, however, this is often not possible
Coverage may be achieved by split-thickness skin graft, free tissue trans-fer, or local rotation flaps, according
to surgeon preference and institution capabilities
Results
In 1986, Myerson et al9published a retrospective study of 76 TMT joint injuries treated over a 10-year
peri-od Six open injuries were included Treatment methods comprised immo-bilization alone, closed reduction and casting, closed reduction and percu-taneous K-wire fixation, and open re-duction followed by K-wire fixation Fifty-five injuries were followed up
at a mean of 4.2 years (range, 1.6 to
11 years) Immobilization alone or closed reduction and casting
result-ed in 0 of 5 and 3 of 15 (20%) good and excellent results, respectively In contrast, good to excellent clinical re-sults were documented in 9 of 17 pa-tients (53%) who underwent closed reduction and percutaneous pinning
as well as in 14 of 18 patients (78%)
Figure 5 Typical fixation scheme for a TMC
disruption.
Figure 6 Restoration of cuboid length with bone graft and a plate An external fixator or distractor may be used intraoperatively to fa-cilitate distraction (Adapted with permission from Hansen ST Jr: Acute fractures in the foot,
in Hansen ST Jr: Functional Reconstruction of the Foot and Ankle Philadelphia, PA:
Lippin-cott Williams & Wilkins, 2000, pp 65-103.)
Trang 7treated with open reduction and
K-wire fixation Seven of the eight
di-rect crush injuries had fair to poor
functional outcomes (88%) Overall,
the quality of reduction, which was
a subjective assessment of TMT joint
alignment, correlated with the
clin-ical result Good to excellent results
were achieved in 22 of 26 patients
(85%) with an acceptable reduction
and in only 5 of 29 patients (17%) with
an unacceptable reduction The
au-thors concluded that the major
deter-minants of unacceptable results are
the damage to the articular surface
at the time of injury and the quality
of the initial reduction.9
In 1988, Arntz et al6published their
results of 41 TMC injuries in 40
pa-tients treated with open reduction and
screw fixation Seven of the injuries
were open fracture-dislocations.At
sur-gery, intra-articular fracture or
peri-articular comminution was noted in
54% of injuries (22/41) Anatomic
re-duction (within 2 mm) was achieved
in 97% of the closed injuries (33/34)
and in 88% overall (36/41) Hardware
was removed from all patients at a
min-imum of 12 weeks Thirty-four patients
(35 injuries) were followed up at a
mean of 3.4 years after injury Good
or excellent functional results were re-ported for 93% of closed injuries (27/
29) In contrast, four of the six patients with open fractures had a fair or poor functional result In all patients, the presence of degenerative changes on follow-up radiographs negatively cor-related with functional outcome Ra-diographic evidence of posttraumatic degenerative changes was absent or minimal in 26 of the 30 injuries with
an anatomic reduction (87%) Con-versely, all five injuries with nonana-tomic reduction after surgery devel-oped moderate or severe posttraumatic arthritis In general, patients who sus-tained open injuries were more likely
to have periarticular comminution noted intraoperatively, more advanced posttraumatic degenerative changes
at follow-up, and a worse functional outcome The authors concluded that injury to the articular cartilage and fail-ure to achieve an anatomic reduction were the most important determinants
in the development of posttraumatic arthritis Furthermore, they stressed the importance of open anatomic re-duction followed by rigid screw fix-ation in optimizing outcome.6
More recently, Kuo et al5reported
on 92 TMC injuries treated over a 7-year period Six open injuries were included in the study All patients were treated surgically with the me-dial three joints stabilized with screws and the fourth and fifth joints, with Kirschner wires Postoperatively, screws were removed only when painful Forty-eight patients were ex-amined at a mean of 4.3 years after injury (range, 1.1 to 9.5 years), for a follow-up rate of 52% The prevalence
of radiographic posttraumatic
arthri-tis was significantly (P = 0.004) lower
in patients with an anatomic reduc-tion within 2 mm (6/38 [16%]) com-pared with those with nonanatomic reduction (6/10 [60%]) In addition, patients with anatomic reduction had
a statistically significant (P = 0.05)
bet-ter average functional score, as mea-sured by the American Orthopaedic Foot and Ankle Society score for the midfoot Purely ligamentous injuries tended to have a higher prevalence
of osteoarthritis, but without statis-tical significance The authors con-cluded that the overall outcomes af-ter surgical treatment of these injuries are good and that anatomic reduction
is important for long-term outcome.5
Complications
Posttraumatic arthritis remains the most common complication after TMC injury Not all patients who develop degenerative radiographic changes are symptomatic.9In the series by Kuo et
al,512 of 48 patients (25%) had symp-tomatic arthritis at final follow-up Of these, six underwent arthrodesis.Arntz
et al6reported moderate to severe de-generative changes on follow-up ra-diographs in 9 of 35 patients (26%) Cushioned inserts, shoe modifications, and nonsteroidal anti-inflammatory medications are the mainstay of non-surgical treatment for posttraumatic arthritis after TMC injury If these mo-dalities fail, arthrodesis of the affected joints is the treatment of choice
Figure 7 Release of compartment syndrome through dorsal incisions (Adapted with
per-mission from Myerson MS: Experimental decompression of the fascial compartments of the
foot: The basis for fasciotomy in acute compartment syndromes Foot Ankle 1988;8:308-314.)
Trang 8Other complications occur with
less frequency Arntz et al6and Kuo
et al5reported an incidence of broken
screws of 2% and 25%, respectively
Superficial infection, residual
dyses-thesias, late displacement, and deep
vein thrombosis have been reported
in <4% of cases.5,6,9
Summary
Injuries to the tarsometatarsal joint complex are often overlooked and can
be misunderstood An appreciation of the complex bony and ligamentous anatomy is necessary to make an ac-curate diagnosis from the
appropri-ate radiographic studies Open ana-tomic reduction and rigid internal fixation is the preferred method of management The keys to maximiz-ing outcome are maintainmaximiz-ing
anatom-ic reduction (<2 mm) and avoiding complications with safe soft-tissue handling
References
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3 Brunet JA, Wiley JJ: The late results of
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4 Sangeorzan BJ, Veith RG, Hansen ST Jr:
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5 Kuo RS, Tejwani NC, DiGiovanni CW,
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20 cases Clin Orthop 1983;176:154-162.
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