The Journal of Foot & Ankle Surgery 59 (2020) 1139−1143
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The Journal of Foot & Ankle Surgery
journal homepage: www.jfas.org
Treatment of Lisfranc Injuries Using Interosseous Suture Button:
A Retrospective Review of 84 Cases With a Minimum 3-Year Follow-Up
James M Cottom, DPM, FACFAS1, Colin T. Graney, DPM, AACFAS2, Charles Sisovsky, DPM, AACFAS2
1
2
Fellowship Trained Foot and Ankle Surgeon and Director, Florida Orthopedic Foot & Ankle Center Fellowship, Sarasota, FL
Fellow, Florida Orthopedic Foot & Ankle Center Fellowship, Sarasota, FL
A R T I C L E
I N F O
Level of Clinical Evidence: 3
Keywords:
dislocation
foot
fracture
Lisfranc
midfoot sprain
trauma
A B S T R A C T
Lisfranc fracture dislocation is an injury often encountered by the foot and ankle surgeon. This injury, depending
on the severity and level of energy, has been shown to lead to posttraumatic osteoarthritis and chronic pain if
undiagnosed or improperly managed. The purpose of this study was to retrospectively evaluate the surgical repair
with the use of an interosseous suture button for Lisfranc injuries with isolated ligamentous disruption. From
2008 through 2016, 104 patients were consecutively enrolled who underwent open reduction internal fixation
(ORIF) of the Lisfranc complex with a suture button and stabilization of the medial and intermediate cuneiform
with a 4.0-mm screw. Eighty-four patients were available for a 3-year minimum follow-up. The mean return to
full weightbearing was 11 days protected in a controlled ankle motion (CAM) boot. American Orthopedic Foot &
Ankle Society (AOFAS) and visual analog scale (VAS) scores improved from 30 and 8.4, respectfully, preoperatively
to 90 and 1.3 postoperatively. The mean preoperative step-off between the second metatarsal base and intermediate cuneiform was found to be 3.15 mm. The immediate postreduction weightbearing radiograph measured
0.25 mm and 0.43 mm at the final follow-up evaluation, a difference that was found to be significant. There were
no revision arthrodeses performed and no removal of the suture button during this time period. ORIF using
an interosseous suture button appears to have an adequate medium-term patient satisfaction; however,
there is evidence of minimal diastasis in some patients at 3 years postoperatively in ligamentous Lisfranc fracture
dislocations.
Published by Elsevier Inc. on behalf of the American College of Foot and Ankle Surgeons.
For foot and ankle surgeons, Lisfranc fracture dislocations can be
highly concerning if neglected. Lisfranc injuries are relatively uncommon, as they account for 0.2% of all fractures, but the true prevalence is
likely higher because they frequently go undiagnosed (1). This injury
may present as an acute injury or one that has been neglected or missed
from prior trauma. Approximately 20% of the 55,000 annual Lisfranc
injuries are misdiagnosed upon initial presentation (2−4). When this
injury is misdiagnosed, or missed altogether, the result can lead to posttraumatic midfoot osteoarthritis (1,5,6). Because of the subtlety of this
injury, advanced imaging beyond plain films has been recommended,
ie, magnetic resonance imaging (MRI), for evaluation of the Lisfranc ligament and deviation of the tarsometatarsal articulations (7−9). Upon
evaluation of weightbearing films, a Lisfranc injury can be visualized if
a shift >2 mm is observed (10).
Before many surgical advances, the Lisfranc fracture/dislocation was
initially treated conservatively with below-knee cast immobilization for 8
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: James M Cottom, DPM FACFAS, Florida Orthopedic Foot &
Ankle Center Fellowship, 1630 S. Tuttle Ave., Sarasota, FL 34239.
E-mail address: jamescottom300@hotmail.com (J.M. Cottom).
to 12 weeks (5,6,11−13). Currently, there are limited indications for conservative treatment with cast immobilization (12,14,15). As time has progressed, a multitude of varying techniques for surgical repair have been
proposed. Because of the vast amount of research within this anatomic
location, a wide array of varying successes regarding fixation preferences
of primary arthrodesis versus open reduction with internal fixation (ORIF)
have been reported (12,14−16). Arthrodesis after severe injury with multiple intra-articular fractures and dislocation involving multiple articulations has been recommended (14,16). Conversely, reports have
demonstrated the superiority of ORIF against arthrodesis (17). In regard to
ORIF, there have been discussions about whether a second procedure is
required for hardware removal or arthrodesis in the setting of posttraumatic arthritic changes (17−19). When discussing ORIF of Lisfranc fracture
dislocations as opposed to arthrodesis, achieving anatomic reduction as
well as maintenance of reduction is critical. Screw complications are
reported in 16% and posttraumatic arthritic changes in 40% to 94% of cases
(12,14). The risk ratio for hardware removal is 0.23 with ORIF; however,
this figure was with prior traditional plate and screw fixation (19). Use of
a suture button for ORIF of the Lisfranc joint has been described in the literature with satisfactory results, including the ability to achieve anatomic
reduction and maintain correction (11,13,20−23).
1067-2516/$ - see front matter Published by Elsevier Inc. on behalf of the American College of Foot and Ankle Surgeons.
https://doi.org/10.1053/j.jfas.2019.12.011
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The goal of this study was to evaluate radiographic reduction and
functional outcomes after interosseous suture button and stabilization
of the medial-intermediate cuneiform with a screw, in only ligamentous ruptures of Lisfranc ligament with displacement. A total of 84
patients were retrospectively included in this study, with a minimum
3-year follow-up.
Methods
A retrospective cohort analysis was performed for any patient who underwent a tarsometatarsal ORIF with a ligamentous injury only. Chart analysis was performed based on
the senior author’s records. All patients who had a confirmed primarily ligamentous Lisfranc injury from August 2008 through April 2016 were consecutively enrolled. Inclusion
criteria were any patient ≥17 years of age, those who had a confirmed Lisfranc injury via
MRI or computed tomography (CT) scan in conjunction with plain radiography, and
patients followed up within 14 days from onset of pain or inciting injury. Those patients
who sustained fractures of the foot or any other part of the body were excluded. There
are multiple classification systems for evaluation of the Lisfranc injury (2,24). The authors
used the classification by Nunley and Vertullo (24). All cases were stage 1 or 2 injuries,
indicating a plantar Lisfranc ligament rupture with no diastasis or a diastasis of 2 to
5 mm, and no loss of arch height (Fig. 1).
Demographic data including age, sex, and laterality were evaluated (Table 1). Visual
analog scale (VAS) scores as well as American Orthopedic Foot & Ankle Society (AOFAS)
scores were obtained preoperatively, at a minimum of 36 months, and for some patients
as long as 5 years, with an average follow-up of 3.4 years (Table 2). Radiographic analysis
was performed evaluating for loss of correction, determined by a shift from the medial
aspect of the intermediate cuneiform to the medial base of the second metatarsal from
immediate postoperative weightbearing films to the final comparative evaluation at a
minimum of 1 year. Postoperative weightbearing plain films were obtained at predetermined increments of 2 weeks, 6 weeks, and 6 months and yearly after that. All radiographs were performed weightbearing for consistency and evaluated by a fellowshiptrained foot and ankle surgeon. All radiographic measurements were done with a digital
measuring tool on a picture archiving and communication system radiographic system.
All procedures were performed by the senior author from August 2008 through April
2016 using a 2-incision approach. The first incision was placed over the second intermetatarsal space near the base of the second metatarsal (Figs. 2 and 3). The second incision
was placed medial to the medial cuneiform for the 4.0-mm screw to be placed from the
medial cuneiform into the intermediate cuneiform. A large tenaculum clamp was used to
aid reduction (Fig. 4). The 1.35-mm guidewire was first placed from the lateral second
metatarsal base to the medial cuneiform for the suture button (Fig. 5). The suture button
was then placed to secure the reduction (Fig. 6). Secondarily, a 4.0-mm partially threaded
Fig. 1. Lisfranc fracture dislocation.
Table 1
Demographics
Characteristic
Value
Sex
Male
Female
Foot
Left
Right
Age (y)
50 (59.5)
34 (40.5)
43 (51.2)
41 (48.8)
39.69 (17 to 72)
Data are n (%) or mean (range).
Table 2
Scoring system
Preoperative VAS
Postoperative VAS
Preoperative AOFAS
Postoperative AOFAS
Score
Standard Deviation
8.41
1.3
30.96
90.36
1.73
1.57
25.75
12.18
Abbreviations: AOFAS, American Orthopaedic Foot & Ankle Society; VAS, visual analog
scale.
intercuneiform screw was placed from medial to lateral in conjunction with the suture
button (Figs. 7 and 8).
Statistical Analysis
All data were collected, and inclusion and exclusion criteria were
applied, resulting in 84 patients; 20 patients did not meet the minimum
3-year follow-up. Student’s t test was performed to evaluate the categorical variables between the preoperative and postoperative scores,
Fig. 2. A freer is used under fluoroscopic guidance to outline the incision placement.
J.M. Cottom et al. / The Journal of Foot & Ankle Surgery 59 (2020) 1139−1143
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Fig. 5. Anatomic reduction with guidewire traversing for suture button placement.
Fig. 3. Incision placement dorsally with projected orientation of the suture button placement.
Fig. 4. Fluoroscopic evaluation to ensure adequate reduction.
displacement, sex, and laterality. The mean time to full weightbearing
in a controlled ankle motion (CAM) walker as well any revisions,
including hardware removal, were also included for evaluation.
Results
After the application of inclusion/exclusion criteria, 84 patients were
identified with Lisfranc injuries based on clinical exam and radiographic
evidence and confirmed with MRI. There were 50 males (59.5%) and 34
females (40.5%). There were 43 left (51.2%) and 41 right (48.8%) feet
involved. The mean age was 37.7 years (range 17 to 72). A minimum follow-up of 3 years was required for radiographic evaluation, with an
average of 3.4 years (range 3.04 to 5.99) from the first postoperative
Fig. 6. Suture button in place, securing reduction.
weightbearing radiograph to the final weightbearing radiograph. Preoperative VAS and AOFAS scores were 8.48 (range 5 to 10) and 31.96
(range 15 to 68), respectively, and postoperative VAS and AOFAS scores
were 1.30 (range 0 to 7) and 90.64 (range 78 to 100) (p < .05). The mean
time to protected full weightbearing in a CAM walker was 11 days
(range 3 to 28). The preoperative step-off was measured at a mean
of 3.15 mm (range 0 to 6.4) using non-weightbearing MRI and CT. Non-weightbearing evaluation was performed secondary to trauma and risk
of further displacement. The first postoperative weightbearing films
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intercuneiform screw secondary to loosening or residual pain. Routine
removal of the intercuneiform screw was not performed. There was no
evidence of suture button failure or removal in any of the patients.
Discussion
Fig. 7. Suture button in place with single screw placed between the medial and intermediate cuneiform to intercuneiform instability.
Fig. 8. Suture button in place before intercuneiform screw being inserted. Note the anatomic reduction of the midfoot.
revealed a post-eduction step-off of 0.22 mm (range 0 to 0.48). The final
weightbearing radiographs demonstrated a step-off of 0.43 mm (range
0 to 1.13), which was found to be statistically significant (p < .05). Nine
patients (10.7%) underwent hardware removal of the 4.0-mm
ORIF of the acute Lisfranc fracture/dislocation is a relatively common
procedure performed by the foot and ankle surgeon. With the goal of
obtaining anatomic restoration and prevention of posttraumatic osteoarthritis, maintenance of reduction is critical. Intra-operative adequate
anatomic reduction with appropriate tension may be difficult to obtain
owing to the inability to truly simulate weightbearing. Stress radiographs, whether clinically or intra-operatively, have been shown to be
able to evaluate intermetatarsal and intercuneiform diastasis (25,26).
Because of the instability of the medial and intermediate cuneiform,
the authors routinely use an intercuneiform 4.0-mm screw to address
the potential for diastasis (27). In contrast to Ardoin and Anderson’s
study (27), whose postoperative protocol included a total of 6 weeks of
non-weightbearing followed by an additional 6 weeks of protected
weightbearing, the current cohort was able to return to weightbearing
4 weeks sooner.
A common discussion is whether routine hardware removal after
ORIF is required. VanPelt et al (18) retrospectively reviewed 61 patients
who underwent ORIF with 3.5-mm fully threaded cortical screw fixation. They demonstrated that 80% of patients will have no evidence of
hardware failure, with a 20% complication rate. Because hardware failure is a concern with ORIF, 16% to 20% of surgeons have elected for
arthrodesis with the desire to avoid additional procedures (12,14,18).
Henning et al (17) demonstrated that ORIF can have similar patient satisfaction results compared with primary arthrodesis. In that study,
there was a significantly larger number of secondary surgeries within
the ORIF group as opposed to the arthrodesis group, 78% versus 16%,
respectively. They did find 1 trend that arthrodesis performed better
than ORIF on the arm/hand index of the short musculoskeletal functional assessment questionnaires (SMFA). The SMFA is an abbreviated
(46-question) version of the musculoskeletal functional assessment
(MFA), which is 101 questions. This questionnaire has been validated
for consistency and reproducibility (28). Also, the article did not mention the particular reason for secondary surgery and whether it was
prophylactic hardware removal (17).
Suture buttons have demonstrated the ability to not only achieve
anatomic reduction, but also maintain reduction. The study by Cottom
et al (20) compared a trans-syndesmotic screw to the Tightrope
(Arthrex, Naples, FL) for syndesmotic repair, allowing for motion within
the syndesmosis during tibiotalar motion. This motion that is allowed
at the syndesmosis can be directly correlated to the motion within the
midfoot. Despite this motion through the midfoot being relatively minimal, the flexibility of the nonabsorbable suture within the suture button allows this motion, preventing additional subjective stiffness
postoperatively (29). When patients previously underwent ORIF using
the “home run” screw fixation to recreate the Lisfranc intermetatarsal
ligament, the motion through the midfoot would create either screw
breakage due to fatigue or backing out of the screw (30). The suture
button’s ability to secure on 2 cortices theoretically prevents the repair
from shifting. The authors also believe that the approximation of the
ruptured ligament ends with the nonabsorbable suture in place gives
the ligament the ability to repair at the appropriate tension and maintains fluidity within the lesser tarsus, creating a similar strength to preinjury levels (31).
Despite there being statistical significance of an increase in step-off
as time progresses, a 0.2-mm increase in diastasis on average, this
change in diastasis can be related to patient positioning for the radiographs as well as changes in weightbearing from the initial postoperative radiograph (guarding) and the final radiograph.
J.M. Cottom et al. / The Journal of Foot & Ankle Surgery 59 (2020) 1139−1143
The authors also believe that there is a spectrum for selecting the
type of procedure regarding ORIF versus primary arthrodesis, in agreement with Ly and Coetzee (14), indicating that with severe intra-articular fractures or >5 mm displacement, an arthrodesis may be preferred
due to the amount of cartilaginous damage incurred at the time of
injury. The authors realize there are limitations to this study, including
its retrospective nature as well as to the limited follow-up period. There
has also been an inconsistency in the ORIF construct as technology has
changed. To improve on the study, more accurate postreduction imaging (CT, MRI) with simulated weightbearing would be recommended
for more accurate results.
In conclusion, the authors use this technique for primary injuries
with purely ligamentous pathology and minimal displacement. As demonstrated, we have found that ORIF using an interosseous suture button
appears to have adequate medium-term patient satisfaction for Lisfranc
fracture dislocation, with no evidence of suture button failure or catastrophic loss of anatomic alignment that can lead to posttraumatic
arthritis or revisional arthrodesis procedures.
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