I. Definition and epidemiology
Chopart joint, also known as intertarsal joint or transverse tarsal joint, consists of heel dice joint and talofibular joint, which are in inversion and valgus position respectively with reference to the subtalar joint. The Lisfranc joint consists of a metatarsophalangeal joint complex, including the medial, middle and lateral cuneiform bones, the dice bone and the articular surface formed with five metatarsal bones. The Lisfranc joint forms the basis of the longitudinal and transverse arches of the foot (Fig. 1).
Figure.1
Anatomical view of the midfoot bone structure. Figure.1-A, upper view; Figure.1-B, lower view; Figure.1-C, medial view; Figure.1-D, lateral view; Figure.1-E, coronal view. Note the red lines in Figs. 1-A and 1-C, which indicate the normal alignment of the midfoot,
The midfoot fractures involving the Chopart and Lisfranc joints are very easy to miss in clinical practice. 33% of these injuries have no obvious radiographic manifestations, and many clinicians are unfamiliar with these fractures. According to statistics, injuries to the Chopart joint are extremely rare in clinical practice, while injuries to the Lisfranc joint complex are also uncommon, with an annual incidence of only 0.2% or 1/55,000 for these two joints. nearly 1/3 of these injuries are caused by low-energy injuries similar to sports injuries, mostly occurring at the same time as other midfoot injuries, which further increases the difficulty of diagnosis.
B. Anatomy of bone and soft tissue structures
The Chopart joint consists of the talonavicular joint and the saddle-shaped heel dice joint. The talonavicular joint is a ball and socket-like joint with a deep pocket on the proximal side of the navicular bone, which contains the talar head and can provide partial joint stability. Associated structures also include the anterior and medial surfaces of the heel bone, the plantar ligament of the heel navicular and the Y-shaped divergent ligament (Figure.2). The heel dice joint is depressed in the vertical plane and raised in the transverse plane, formed by the anterior articular surface of the heel bone and the posterior articular surface of the dice bone, which is a highly conformal joint that is “locked” when the foot is on the ground.
Figure.2 Anatomy of the foot socket
The Lisfranc joint consists of the anterolateral and proximal intertarsal joints and is the key structure of the longitudinal and transverse arches of the foot. In cross-section, these structures are arranged in a trapezoidal “Roman arch” structure, which maintains the lateral stability of the joint, while the second tarsal base is critical to maintaining the longitudinal stability of the joint. The 1st, 2nd and 3rd tarsal bones form the articular surfaces with the corresponding cuneiform bones, while the 4th and 5th tarsal bones form the joint on different surfaces of the dice bone. (Fig.1). The stability of these small joints is maintained mainly by ligamentous structures.
The joint capsule of the Lisfranc complex can be divided into 3 intervening compartments (accordingly dividing this joint into 3 columns), which encircle the 1st metatarsal tarsal joint, the 2nd and 3rd metatarsal tarsal joints and the 4th and 5th metatarsal tarsal joints, respectively. And the ligaments around the joint can be divided into 3 groups: dorsal, interosseous and metatarsal. Among them, the interosseous ligaments are the strongest and are very important for the stability of the joint. This structure is present between all tarsal bones except for the 1st-2nd tarsal bones. The Lisfranc ligament is the strongest interosseous ligament, which is responsible for the frequent occurrence of metatarsal avulsion fractures at the base of the 2nd tarsus in midfoot fracture-dislocation injuries (Fig.3). The metatarsal ligament is stronger than the corresponding dorsal ligament group, which helps to maintain the “Roman arch” structure of the midfoot.
Figure.3
Non-weight-bearing orthopantomogram (AP) radiograph of the foot. The medial edge of the base of the 2nd metatarsal is separated from the lateral edge of the medial cuneus by >2 mm, noting the avulsed bone mass in between.
The dorsalis pedis artery crosses the Lisfranc joint and passes between the base of the 1st and 2nd tarsal bones towards the metatarsal side to form the metatarsal artery arch. In the event of midfoot fracture-dislocation, the dorsalis pedis artery is susceptible to laceration or embolization in this area, resulting in a hematoma or fascial compartment syndrome. The deep peroneal nerve runs with the dorsalis pedis artery and innervates the dorsal area of the webs of the 1st and 2nd toes.
Several tendons are associated with the Chopart and Lisfranc joints, the most important of which are the anterior tibial tendon and the peroneus longus tendon. The anterior tibial tendon terminates dorsal to the base of the 1st metatarsal and the medial cuneus and is the dynamic stabilizing structure of the 1st metatarsophalangeal joint. When the joint is dislocated, the anterior tibial tendon may become trapped between the medial and medial cuneiform bones and cause difficulty in repositioning. The peroneus longus stops at the lower lateral aspect of the 1st metatarsal, which can dynamically support the longitudinal and transverse arches of the foot.
III. Biomechanics of the midfoot
The “column” theory helps to understand the anatomy and biomechanics of the midfoot, and the Chopart joint can be divided into medial and lateral columns. The medial column includes the talus and the navicular bone (talonavicular joint), which are movable joints; the lateral column includes the heel bone and the dice bone (heel-dice joint), which are micromotor joints. The distal end of the medial column is connected to the three cuneiform bones and the 1st, 2nd and 3rd metatarsals, and there is little movement between these structures. The distal end of the lateral column is connected to the 4th and 5th metatarsals, which are movable joints. The entire midfoot consists of the medial and medial cuneiform bones and the 2nd and 3rd metatarsals and their associated ligamentous structures forming the middle column, with the 2 remaining structures on the sides forming the medial and lateral columns, respectively. The medial column of the midfoot can produce 3.5 mm of relative motion in the dorsal-plantar direction. The rigidity of the entire midfoot is maintained mainly by the medial column structure, while the lateral column mainly performs the function of shock absorption.
The Chopart joint and the subtalar joint form a functional unit to perform the internal and external rotation of the foot. When the heel is turned out, the heel dice joint and the talocrural joint are aligned in parallel and the Chopart joint is in motion, while when the heel is turned in, the Chopart joint will become “locked” and immobile, and the whole midfoot will be in a fixed state, which is common in the push-off phase of the gait cycle (Fig. 4 ). This process is also known as the “winch mechanism”. During the push-off phase, the first metatarsal tarsal joint undergoes significant dorsiflexion, and the plantar tendons and fascia are tightened, causing elevation of the longitudinal arch and inversion of the heel bone, resulting in locking of the Chopart joint and immobilization of the midfoot and longitudinal arch.
Figure.4
Function of the Chopart joint. The left figure shows the foot exostosis with the 2 joints in parallel alignment. The right figure shows the inversion of the foot, where the 2 joints are no longer parallel. The figure highlights the multidimensional motion of the talonavicular joint complex and the hindfoot. tn =
TN = talonavicular joint; CC = calcaneocuboid joint
IV. Mechanism of injury
Most intertarsal and metatarsophalangeal joint injuries occur when the foot is plantarflexed and subjected to axial load or torsional stress. The injury is usually at the base of the 1st and 2nd metatarsal bones and is followed by medial or lateral dislocation depending on the direction of the stress. The internal stresses tend to result in fractures and dislocations of the base of the 2nd metatarsal, as well as compression fractures of the cuneiform bone, known as “nutcracker” injuries.
Midfoot crush injuries or falling object injuries (where the violence is directed to the dorsal aspect of the midfoot) are rare, but are often associated with severe soft tissue and/or neurovascular injury, with a greater likelihood of subsequent pedal fascia compartment syndrome.
If x-ray suggests destruction of the metatarsophalangeal joint without a clear clinical history to support it, Charcot’s arthropathy (Charcot
neuroarthropathy). Although this disease is only seen in a small percentage of patients with diabetic neuropathy, the midfoot is the site of this disease and may even be the first manifestation in some diabetic patients. If these patients can be accurately diagnosed and treated properly, they can save their limbs and lives.
V. Injury typing
In 1975, Main and Jowett proposed a staging system based on the mechanism of injury, but it was not well accepted. In contrast, the staging system proposed by Qu´enu and Küss in 1909 was widely used, and was modified by Hardcastle et al. in 1982 to include three injury patterns: bifurcation, isolation, and ipsilateral. The advantage of this staging system is that it identifies the entry and exit points of violence or energy in different regions of the midfoot, which is the basis for the diagnosis and treatment of midfoot injuries. In the original staging system, midfoot injuries were classified into 3 types: type A, for overall separation; type B, for partial separation; and type C, for bifurcation-type separation. In 1986, Myerson further subdivided the latter 2 types into type B1, a partially separated medial displacement; type B2, a partially separated lateral displacement; type C1, a partially separated bifurcation; and type C2, a separated bifurcation with an overall displacement. In their typing system, not only metatarsophalangeal joint injuries are included, but also intercuneiform and navicular cuneiform joints (Figure.5)
Figure.5
Myerson’s typing of metatarsophalangeal joint injuries. The arrow in the figure indicates the bifurcation type injury
VI. Diagnosis of midfoot injury
Midfoot injury should be highly suspected in patients with pain and swelling of the foot with metatarsal ecchymosis. The initial rate of missed diagnosis of midfoot injuries can be as high as 20%. Standard imaging examinations should be performed, including orthogonal, lateral and oblique X-rays of the foot, and care should be taken when taking oblique films parallel to the metatarsophalangeal joint. If the medial cuneiform is separated from the 2nd metatarsal by >2 mm, this is indicative of instability (Figure.3). CT scans provide a better understanding of the fracture pattern, but they are not used to determine midfoot stability because they only show static images and cannot be examined in a weight-bearing position. However, the “speckle sign” or finding of an avulsion fracture, even if the bone mass is small, can indicate midfoot instability.
If there is no positive finding on non-weight bearing imaging, weight bearing X-ray should be performed. On a standing orthopantomograph of both feet, subtle differences between the feet can be effectively detected by bilateral comparison. As shown in Figures 1-A and 1-C, the talus-foot navicular-medial cuneiform and 1st metatarsal should be aligned in a straight line on both the frontal and lateral radiographs, and any abnormalities are indicative of joint subluxation and fracture. When the patient is unable to perform weight-bearing radiographs due to pain, stress-position radiographs can be performed under anesthesia to rule out midfoot joint instability. Stress radiographs can be performed in the following order: first, an inversion and rotation of the foot in the anterior position; in the second step, pressure is applied to the medial and middle columns of the midfoot and a parallel x-ray is performed. Both of these examinations can induce a metatarsophalangeal joint displacement, if present. In contrast, flexing the midfoot along the Lisfranc joint and performing a lateral dynamic x-ray in this position can help detect a subluxation or separation of the dorsal joint.
If the diagnosis cannot be confirmed after these examinations, MRI is feasible to evaluate the soft tissue of the midfoot (Figure.6). Recently, Raikin et al. found a correlation between MRI findings and stress radiographs. Their findings showed that metatarsal Lisfranc ligament rupture was highly correlated with joint instability. They also proposed a clinical algorithm to determine the need for stress radiography for the differential diagnosis of patients with an intact metatarsal Lisfranc ligament and a positive “patchy” sign on plain radiography. It should be noted, however, that MRI is also a static imaging study and cannot be used to determine joint instability.
Figure.6
Coronal T-2 weighted MRI image of an adolescent patient with midfoot pain showing an intact Lisfranc ligament on the metatarsal side.
Indications
Stable fractures without displacement are suitable for conservative treatment. Such cases require short-leg cast immobilization and weight restriction for 4-6 weeks, followed by weight training in an orthopedic boot or brace once symptoms have resolved. In the case of metatarsophalangeal joint displacement, surgical treatment is indicated regardless of the stress radiographic findings.
VII. Preoperative planning and/or pre-treatment
Once a case of acute injury to the Lisfranc and Chopart joints has been diagnosed, it should be repositioned immediately to reduce the surrounding soft tissue pressure and to protect the skin activity around the injured area. If the joint remains stable after repositioning, it can be temporarily immobilized in a splint and await follow-up treatment, usually for 2 weeks. Unfortunately, most cases of high-energy Lisfranc joint injuries do not remain stable after repositioning and require external fixation and, if necessary, the addition of 1-2 kerf pins to increase the strength of the fixation. Unreliable temporary fixation can aggravate the surrounding soft tissue damage and may even cause total skin necrosis. Displaced midfoot fractures are difficult or impossible to reset anatomically until the soft tissue swelling subsides, and waiting for the swelling to subside will be time consuming, so good repositioning and reliable temporary fixation should be performed early to facilitate soft tissue recovery.
In cases of shortened deformity of the lateral midfoot column due to displacement of the 4th and 5th metatarsal-dice bone complex or compression fracture of the dice bone, only single-arm external frame fixation is required to maintain stability, whereas in cases of simultaneous injury or shortened deformity of the medial and lateral columns (e.g., axial violence to the midfoot with simultaneous compression fractures of the dice bone, navicular and/or cuneiform bones, as in Figure.7), bilateral external frame fixation is required. The external frame technique and the corresponding care measures have been described in detail in previous studies. In patients with Lisfranc injuries, the elasticity of the gastrocnemius muscle should also be evaluated; if there is stiffness or contracture, this will leave the ankle in a horseshoe-foot-like state and will require concurrent gastrocnemius recession for correction. Follow-up open repositioning and internal fixation will be performed after the soft tissue swelling has completely subsided.
Figure.7
Orthopantomogram of the foot of a patient who underwent fixation with a double-armed external frame. The medial and lateral arms of the external frame are connected by a Searle pin via the heel tuberosity
VIII. Late surgical technique
The many joints of the midfoot can be divided into essential and nonessential joints. Essential joints refer to the mobile joints that are closely related to the function of the midfoot, while non-essential joints are those with minimal or no movement. Any surgical treatment requires reconstruction or preservation of the essential joints. The non-essential joints can be repositioned and fixed by fusion or permanent implantation. The essential joints of the midfoot include the talonavicular and heel dice joints, as well as the dice bone and the joints between the 4th and 5th metatarsals. The remaining joints of the midfoot are nonessential and include: the 1st, 2nd, and 3rd intermetatarsal joints, the intercuneiform joint, and the navicular-cuneiform joint.
The rehabilitation and internal fixation procedure should be based on the following strategy: first, the medial column must be kept stable, even if the movement of the metatarsophalangeal joint is thus limited, so that the 1st, 2nd, and 3rd metatarsals can be fixed with the adjacent cuneiform bone if necessary. Second, the motion of the lateral column (4th and 5th metatarsals with the dice bone) and the talofibular joint must be preserved.
Overall, the resetting of Lisfranc injuries can follow a proximal to distal, medial to lateral sequence. After repositioning, temporary fixation with kerf pins may be performed if necessary to maintain the fracture mass in position. The medial external fixation frame should be removed prior to medial column repositioning, and if the length of the medial column is difficult to maintain, temporary fixation with a Kirschner pin may be performed prior to removal of the external frame.
The repositioning of the navicular fracture should precede the cuneiform fracture and should be performed on the dice fracture after the fixation of the medial column metatarsophalangeal joint separation is completed. The skin incision and muscle stripping procedures required for metatarsophalangeal joint repositioning are detailed in Table I. The routine surgical techniques described above are important, but may require some variation on them in cases with combined other fractures or foot avulsion injuries. The surgical incision can be chosen as needed, with medial, lateral, or dorsal skin incisions of the foot being acceptable. The metatarsal incision should not be chosen except in cases where the CT examination clearly indicates a comminuted fracture of the metatarsal base of the metatarsophalangeal joint. If the dice bone or heel injury is more complex, the external fixation frame may be retained until about 8 weeks after the second-stage internal fixation to facilitate early postoperative activity, stretching exercises, and massage.
Table I Skin incision to expose the metatarsophalangeal joint and the musculature to be stripped
Step 1: Temporary fixation of the medial column
The 1st metatarsal is pried and the proximal articular surface is reset with reference to the medial cuneiform. The soft tissues are retracted medially to ensure that the medial edge of the medial cuneiform and the 1st metatarsal are evaluated under direct vision for repositioning. Any gap or parallel displacement between the two should be eliminated to achieve a perfect repositioning. Temporary fixation with kerf pins is performed after the completion of the reset until the final internal fixation is completed. Two kerf pins are placed during the 1st, 2nd, and 3rd metatarsophalangeal joint resets, one to ensure stability after resetting and the other as a guide pin for final fixation (Figs. 8-A,8-B,8-C).
Fig.8-A
Figure.8-B
Figure.8-C
Intraoperative radiographs of a patient with a midfoot fracture. The image is shown after completion of medial column repositioning and temporary fixation; A is an orthogonal image, B is an oblique image, and C is a lateral image. The 3rd metatarsal and lateral cuneiform show a folded joint edge, suggesting that the joint surface has been repositioned
The base of the 2nd metatarsal forms the apex of the transverse arch of the foot and is the key to repositioning. It should be exposed and fixed through incision A (Table I). The joint capsule of the 2nd metatarsal-medial cuneiform joint needs to be incised to directly expose the lateral aspect of the joint. It is important to reposition this joint both medially and laterally, and after repositioning, a kerf pin can be placed slightly laterally and centrally on the medial edge of the 2nd metatarsal for temporary fixation. Incision B is primarily used to expose the base of the 3rd metatarsal and the lateral cuneiform. (Table I)
Step 2: Final fixation of the lateral column
After completing the repositioning and temporary fixation of the medial column, the treatment of the lateral column is continued. The 4th and 5th metatarsals usually undergo dorsal displacement and show mostly diffuse separation on radiographs rather than folds in the articular surface. The repositioning of the lateral column can be judged by oblique fluoroscopy of the medial edge of the dice bone, and the alignment of the 2 joint lines is consistent to suggest satisfactory repositioning. The lateral repositioning of the lateral column can be accomplished under direct vision through incision C (Table I). After the repositioning, temporary fixation was also required by placing 2 kerf pins. The first one is inserted through the base of the 4th metatarsal and passes through the articular surface to the medial corner of the dice bone. The second pin is inserted from the 5th metatarsal through the center of the joint to the medial corner of the dice bone.
Once temporary fixation is complete, we prefer to cut all of the kerf pins short so that they are below the skin to minimize skin-related complications, which are usually caused by soft tissue swelling.
Step 3: Final fixation of the medial column
Fixation between the navicular and cuneiform bones of the foot can be achieved with an optional transarticular endoprosthesis, which provides maximum stability. The 1st metatarsophalangeal joint can be fixed with 2 screws (Figs. 8-D,8-E, and 8-F). The first screw is screwed in from the lateral side of the 1st metatarsal, towards the proximal and metatarsal side into the medial cuneiform. If screwing from the dorsal side is required, a countersunk screw should be selected to avoid abrasion of the thumb extensor tendon by the tail of the nail. The other screw is screwed in from the medial cuneus towards the metatarsal eminence of the base of the 1st metatarsal. For final fixation of the 2nd and 3rd metatarsal joints, a 3.5mm screw or “Lisfranc” 4.0mm screw is screwed into the joint directly using the centrally located kerf pin as a guide pin. These 3.5mm and 4.0mm screws have a 2.7mm tail, which reduces the wear on the extensor tendon. The skin incision is closed with Donati-Allgöwer sutures and the suturing technique to protect the blood supply to the skin margin is described in Ref. 23.
Figure.8-D
Figure.8-E
Figure.8-F
Intraoperative radiographs of the patient with a foot fracture in Figure.8. The figure shows the final fixation of the medial column after completion.D, orthogonal image; E, oblique image; F, lateral image. The screws between the 1st metatarsal and the medial cuneiform should be screwed in such a way that the 2 screws are arranged crosswise, and the retained kerf pins should be bent toward the metatarsal surface to reduce the height of their protrusion to avoid local skin and soft tissue pressure
IX. Postoperative treatment
The foot is wrapped with a padded dressing, kept in a neutral position and splinted with an elastic bandage (Ace bandage) wrapped around it. The advantage of using an elastic bandage is that there is no need for secondary adjustment according to the swelling of the ankle joint. If the external fixation of the lateral column is retained, antibiotic therapy (cotrimoxazole) is continued for 6-8 weeks until the external fixation is removed. Postoperatively, quadriceps locking exercises can be started to straighten the knee and stretch the gastrocnemius. It is also necessary to prevent horseshoe foot contracture of the ankle joint.
The stitches are removed 2 weeks after surgery. For patients who have undergone gastrocnemius recession at the same time and are not in a lateral column external fixation brace, a short fiberglass leg brace should be continued to keep the ankle in a neutral position; for patients who have retained the external fixation brace, a plaster splint should be used. After removal of the stitches, passive mobility training of the metatarsophalangeal joint and active mobility training of the hip and knee joints could be started. The brace is replaced with an orthopedic boot for protection 6 weeks after surgery. At 6-10 weeks after secondary surgery, the external fixation brace can be removed along with the fixation pins through the 4th and 5th metatarsal-dice joints, and active ankle and subtalar joint mobility training can be started with orthopedic boots for heel weight bearing as tolerated.
Patients may begin to wear compression compression stockings and orthopedic boots for restoration of walking function in flatfoot gait. Orthotic devices may also be used for related recovery. By 4 months postoperatively, functional recovery of forefoot turning in the orthotic boot can be initiated (Figs. 8-G, 8-H, and 8-I), and walking in normal shoes can be attempted. By 6-9 months postoperatively, if the patient is still experiencing discomfort or if the primary injury is severe, a fitted semi-custom foot pad may be used in conjunction to facilitate recovery. Patients who have undergone gastrocnemius recession should also undergo gastrocnemius strength and stretch strengthening exercises to maintain normal range of motion of the ankle joint. At the same time, balance and proprioceptive training of the lower extremity should be initiated. Patients are evaluated at a final follow-up visit at 1 year postoperatively.
Figure.8-G
Figure.8-H
Figure.8-I
Radiographs of a patient with a midfoot injury at 3 months postoperatively. g, orthopantomogram; h, oblique image; i, lateral image. The figure shows an anatomical repositioning of the medial column movement, and transarticular facet fixation was performed on all nonessential joints used. Note the screw insertion position of the 1st, 2nd, and 3rd metatarsals. Screw insertion through this metatarsal neck area reduces the height of the nail tail and reduces wear.
Complications
Complications related to midfoot injuries are very common. They can be subdivided into surgical-related and non-surgical-related complications. The latter include mainly missed diagnoses and deformities, such as flat feet or traumatic arthritis. Skin or wound healing problems are associated with the timing of surgery (premature), surgical technique (peeling or creation of a flap around the incision) and the time interval between injury and surgical management. Injury to the nerve structures of the foot, including the deep peroneal nerve (which innervates the dorsal region of the 1st toe web), the superficial peroneal nerve, and the peroneal nerve, may also result from the choice of surgical incision or excessive strain during surgery. Awareness and understanding of the relevant anatomic structures is important in this type of surgery. Failure to effectively restore and maintain medial, middle, or lateral column length and missed fascial compartment syndrome may result in regional pain syndrome and should be avoided at the time of temporary external fixation. Anterior tibial artery injury is the most common vascular injury. The position of the subcutaneous endoprosthesis and the protrusion of the screw tail or plate can cause irritation to the surrounding nerve structures or wear to the shoe. Inappropriate internal fixation or inadequate fixation strength can result in internal fixation failure and lead to graft dissection and midfoot collapse. In addition, persistent pain in the foot may result from post-traumatic Achilles tendon contracture, regardless of whether surgical intervention is performed.
X. Prognosis
In a retrospective study, 48 cases of metatarsophalangeal joint injury were followed for a mean of 4.5 years, and the mean AOFAS (American Foot and Ankle Surgery Society) functional score was 77 and the mean MFA (Musculoskeletal Function Rating System) score was 19 in all patients. 1/4 of the patients developed traumatic arthritis, and 12.5% required remedial revision fusion of the joint. Tough anatomic fixation provides the best treatment outcome. The prognosis is poor in cases of ligamentous injury alone, with symptomatic traumatic arthritis present in 40% of such cases, compared with 18% of combined ligamentous-skeletal injuries. An analysis of 25 cases of midfoot injuries that underwent ORIF (open reduction internal fixation) showed that in patients with unilateral column structural injuries, weight bearing on the non-injured or non-injured side was preferred for longer periods after rehabilitation, and the number of joints involved and the severity of arthritis did not affect this gait. Comminution of the column structure and loss of length can result in a shift of the foot axis in the sagittal and coronal planes, which can lead to gait changes and a range of subsequent symptoms. The clinical and functional prognosis is worse in cases of bicolumnar injury, and obesity can also be used as a predictor of poor prognosis.
XI. Controversy.
Fusion VS. ORIF
The function of the foot is related to the column structure and the corresponding joints. The navicular bone of the foot is the key structure of the medial column and needs to be kept rigid to maintain stability of the medial column. The dice bone is the key structure of the lateral column and needs to be flexible to ensure the mobility of the lateral column. The above concepts are discussed in the previous sections on “essential joints” (mobile joints) and “non-essential joints” (minimally mobile joints). Therefore, the choice of treatment modality for each column and joint is very important (including temporary fixation with kerf pins, ORIF and arthrofusion).
In a prospective study, the efficacy of primary joint fusion and ORIF for the treatment of injuries to the medial column and corresponding distal structures (1st, 2nd, and 3rd metatarsal tarsal joints) was compared in 20 patients who underwent ORIF and 21 patients who underwent primary joint fusion. the number of patients who achieved anatomic restoration in the 2 groups was 18 (ORIF group) and 20 (joint fusion group), respectively. The postoperative score was followed up for 4.5 years, during which 5 patients in the ORIF group underwent 2 surgeries for traumatic arthritis and 2 surgeries in the no-fusion group. At follow-up, the mean AOFAS score was 68.6 in the ORIF group and 88 in the joint fusion group. In the activity level assessment, patients in the ORIF group recovered to an average of 65% of their pre-injury activity level, while the fusion group recovered to 92%. Patients in the initial fusion group had better short- to mid-term functional recovery compared to the ORIF group.
In another comparison of ORIF versus primary fusion treatment, 22 patients were randomized to the ORIF group, while 17 patients received primary fusion. All patients were followed up for a minimum of 2 years, and the number of patients who achieved anatomic restoration was 21 (ORIF group) and 16 (fusion group) in the two groups. 78.6% of reoperations were performed in the ORIF group, mainly due to traumatic arthritis and endograft removal. There was no significant difference in the assessment results of the SF-36 and the short form of musculoskeletal function score between the 2 groups, but there was a trend for the initial joint fusion group to outperform the ORIF group. Also, the former group had better short- to medium-term function than the latter.
A retrospective analysis of 185 consecutive cases of Lisfranc injury revealed an overall infection rate of 4.3%. Postoperative pain was present in 30% of patients. The number of metatarsophalangeal joints subject to accrual was not associated with final prognosis. Factors associated with increased reoperation rates included multiple injuries, the time lapse between injury and temporary fixation, and ipsilateral dice and navicular injuries associated with high-energy injuries. Postoperative activity scores were lower in patients who underwent ORIF and in male patients. Removal of the protruding graft only improved the outcome of the subjective evaluation and had no effect on other functional assessment outcomes. Pain and multiple injuries were the most significant predictors of postoperative dysfunction, and such patients had lower postoperative functional scores. Compared to normal values, metatarsophalangeal joint injuries can cause long-term effects on joint motion but not other functional impairments. 91% of patients returned to work, an excellent result, and 41% of patients at work were able to perform foot movements around the clock. Those who did not return to work were patients with multiple injuries or who suffered other injuries that prevented them from working. Effective surgical treatment of metatarsophalangeal joint injuries can restore stability and normal alignment of the foot and, in the absence of conditions such as graft protrusion, long-term functional recovery can be obtained.
XII. Dice bone and foot navicular fracture
The management of dice bone fractures is controversial. Theoretically, it is presumed that the dice bone is protected by both the heel bone and the base of the 4th and 5th metatarsal bones, and no surgical intervention is required in the event of a fracture. Displaced fractures with subluxation or subluxation may require surgical repositioning and fixation to reduce healing time and improve function. With ORIF, reconstruction of the articular surface and a compression implant at the joint edge should be effective in restoring joint continuity. However, anatomic repositioning of the dice bone must be achieved during surgery to restore the length of the lateral column and alignment of the foot (Figs.9-A and 9-B). The fusion of the dice bone joint is often less satisfactory.
Fig.9-A
Fig.9-B
Radiograph of a 69-year-old male patient at 10 years postoperatively. a, orthopantomogram; b, lateral image. This patient underwent ORIF of a dice fracture and allograft bone graft for a midfoot injury, along with anatomically strong fixation of the medial column (1st, 2nd, and 3rd metatarsal tarsal joints). As of the last follow-up, the affected foot had recovered well with no pain or limitation of daily activities and could wear normal shoes.
In a comparative study of surgical and non-surgical treatment of dice fractures, the corresponding surgical intervention was performed in cases of dice fractures with subluxation or dislocation. In terms of complications, there was no significant difference between patients treated surgically or non-surgically, but a higher percentage of surgical patients underwent reoperation for endophyseal wear. Foot navicular fractures mainly cause changes in the wear pattern of the shoe and can increase the chance of secondary osteoarthritis. The prognosis of foot navicular fractures cannot be judged according to the AO/OTA fracture staging system. There is a positive correlation between poor quality of reversion and the incidence of traumatic osteoarthritis.
Occult fractures or subluxations of the navicular may occur and result in persistent pain and discomfort in the foot, when the patient is still able to perform most daily activities, but can adversely affect subjective assessment results. Most lateral column-related injuries require simultaneous stabilization of both the medial and lateral columns. ORIF allows for better anatomical repositioning and restoration of the length of the medial and lateral columns and the arch of the longitudinal arch of the foot, resulting in better outcomes.
Ninety cases of foot navicular fractures treated surgically or non-surgically were observed in the study, all of which were severe injury cases-combined with three or more foot injuries. The prognosis for this group of cases was poor. Patients with combined dice fractures had higher rates of traumatic arthritis, persistent pain, and the need to wear custom-made shoes. Cases with combined talar and distal tibial injuries are almost impossible to return to work. Bone grafting helped improve the quality of fracture repositioning, which was negatively associated with the incidence of pain and traumatic arthritis and postoperative activity level. Obese patients had a higher incidence of postoperative pain and traumatic arthritis and poorer retention after fracture repositioning. The AO/OTA staging system is not effective in predicting the prognosis of cases with combined dice bone fractures.
Foot navicular fractures are quite fragile and require simultaneous restoration of medial column length and articular surface continuity. The quality of fracture repositioning is associated with the chance of developing traumatic arthritis in the distant future. Postoperative pain, traumatic arthritis, and altered foot morphology (inability to wear normal shoes) can adversely affect the assessment of postoperative outcomes. The existing staging system does not provide a valid prediction of prognosis.
XIII. Overview
The Lisfranc and Chopart joints are the distal and proximal joints of the midfoot, respectively. The basic strategy for managing midfoot fractures is to restore motion to the essential joints and to restore stability to the nonessential joints by fusion. High-quality ortho, lateral, and oblique radiographs and CT scans of the foot, with the addition of stress-position radiographs when necessary, are helpful in the diagnosis of midfoot-related losses and fractures, whereas MRI is used primarily to identify damage to the Lisfranc ligament. The timing of surgery should be carefully considered. Severe fractures of the medial and/or lateral columns with shortening must be promptly given temporary fixation with an external fixator.
Waiting for the soft tissue swelling to subside requires a period of time during which a detailed surgical plan should be developed for the fractures of the medial and lateral columns and the corresponding metatarsophalangeal and intermetatarsal joint injuries. Prevention of Achilles tendon contracture should be emphasized during surgical treatment and postoperative rehabilitation, as its occurrence can seriously compromise the outcome of surgical treatment and rehabilitation and further amplify postoperative adverse effects. The prognosis of midfoot injuries needs to be further evaluated, but one can be sure that anatomic repositioning of the bony structures and restoration of the foot alignment are the basis for a good prognosis. Midfoot injuries are very rare in clinical practice, but the ultimate outcome is closely related to the surgeon’s ability. It takes a significant amount of time for the surgeon to complete the entire learning curve and to gain sufficient experience in treatment and surgical skills.