Elective removal of metalwork following Lisfranc injury fixation: Results of a national consensus survey of practice

Management of Lisfranc Injuries: A Critical Analysis Review

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There is a spectrum of midtarsal injuries, ranging from mild midfoot sprains to complex Lisfranc fracture-dislocations.

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Use of appropriate imaging can reduce patient morbidity, by reducing the number of missed diagnoses and, conversely, avoiding overtreatment. Weight-bearing radiographs are of great value when investigating the so-called subtle Lisfranc injury.

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Regardless of the operative strategy, anatomical reduction and stable fixation is a prerequisite for a satisfactory outcome in the management of displaced injuries.

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Fixation device removal is less frequently reported after primary arthrodesis compared with open reduction and internal fixation based on 6 published meta-analyses. However, the indications for further surgery are often unclear, and the evidence of the included studies is of typically low quality. Further high-quality prospective randomized trials with robust cost-effectiveness analyses are required in this area.

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We have proposed an investigation and treatment algorithm based on the current literature and clinical experience of our trauma center.

A Rare Case of a Lisfranc Ligament Transection

Ligamentous Lisfranc injuries, which mimic a surgical transection are rare. Left untreated or missed, these injuries may result in severe complications including long-term disability. The present case describes a unique mechanism of injury via a sharp object puncture through the plantar surface of the midfoot. It highlights the utility of planning staged procedures to remove a large foreign body object, reports notable intraoperative techniques, and provides a decision management guide for treating this type of injury. Extensive surgical planning may be required when encountering similar cases and knowledge of this may be useful to providers.

A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork

Background:

Following Lisfranc injury fixation, no consensus exists on whether to routinely remove metalwork. The aim of this study was to evaluate functional outcomes and complications in patients following routine removal of metalwork and in those with retained metalwork.

Methods:

A systematic review of literature (1999-2020) reporting results of metalwork removal vs retention following Lisfranc injury fixation, was undertaken. The primary outcome was functional outcomes at 1 year following index surgery. Secondary outcomes were rates of complications including unplanned removal of metalwork.

Results:

No studies directly comparing routine metalwork removal vs retention were found. A total of 28 studies reporting on 1069 patients were included. Of these, 10 studies (317 patients) reported on retention and 18 (752 patients) on routine removal of metalwork. The difference in the American Orthopaedic Foot & Ankle Society (AOFAS) score between removal and retention groups was 3.38 (95% CI 6.3-0.48), P = .02 (removal 79.97 [±16.09; 71-96]; retention 76.59 [±20.36; 65.4-94]). No difference in reported rates of infection was found between the 2 groups (0%-12% for both groups). Of the 317 patients in the retention group, metalwork was removed in 198 cases, resulting in a 62.5% unplanned removal rate.

Conclusion:

In conclusion, this systematic review found limited evidence comparing different strategies of metalwork management after Lisfranc injury fixation. A randomized controlled trial is necessary to elucidate if routine removal of metalwork confers any true benefit.

Level of Evidence:

Level IV, systematic review including case series.