A Guide To Dorsal Bridge Plating For Lisfranc Fractures

Facilitating direct visualization and offering rigid stabilization, dorsal bridge plating may be more effective for Lisfranc injuries than transarticular screw fixation. Accordingly, these authors provide keys to the surgical technique and offer a closer look at the emerging literature on bridge plating in the tarsometatarsal joint.

We commonly refer to fracture-dislocations involving the tarsometatarsal joint as Lisfranc injuries. The term derives from a Napoleonic French surgeon who described a tarsometatarsal amputation as a result of soldiers falling from horseback with their foot caught in a stirrup.¹ These injuries account for 0.2 percent of all fractures with an incidence of 1 in 55,000 people per year.^2,3 The mechanism of injury may vary from a low-energy twisting to a high-velocity trauma.^4,5 Depending on the type of impact, the injury can be associated with fractures of the midfoot or may be purely ligamentous in nature.

Diagnosis of a Lisfranc injury is generally through standard weightbearing radiographs. The presence of a “fleck sign” on the anterior-posterior view represents an avulsion fracture off the base of the second metatarsal and is considered diagnostic.⁶ However, not all Lisfranc injuries demonstrate obvious radiographic findings. Researchers have shown that up to 20 percent of these injuries initially go overlooked due to their subtle nature.^4,7 With a heightened index of suspicion, the use of computed tomography (CT) and magnetic resonance imaging (MRI) may help detect these subtler injuries and characterize fracture patterns.

It has been well established that Lisfranc injuries are devastating and often lead to functional impairment. Early diagnosis followed by appropriate treatment is vital to avoid long-term sequelae and post-traumatic arthritis. Ultimately, the ability to obtain anatomic reduction with rigid stabilization is paramount for successful outcomes.^5,6 Traditionally, 2 mm of tarsometatarsal joint displacement is an indication for surgical intervention.¹ Controversies regarding treatments of Lisfranc injuries include the method of reduction, fixation technique and the need for primary arthrodesis.⁴ In the literature, researchers have described various methods such as transarticular screw fixation, dorsal plating, external fixation, neoligamentplasty and Endobutton (Smith and Nephew) stabilization.⁸

Historically, the gold standard of treatment has been open reduction and internal fixation (ORIF) with the use of transarticular screws.^5,9 However, there are several disadvantages with this fixation technique. This method inevitably causes further damage to the articular cartilage of the joints that the surgeon is attempting to preserve.^4,7,9,10 Researchers have shown that the incidence of osteoarthritis is proportional to the area of articular surface damage. Therefore, the placement of intra-articular screws may only lead to further iatrogenic destruction.⁴ Additionally, screw breakage may occur. This may be challenging and technically difficult when removing the distal most screw threads.^4,7,10 Due to the risk of screw breakage, patients may be required to delay early range of motion and weightbearing activities.^4,10

Recent literature supports the use of dorsal bridge plating as an alternative method of fixation for Lisfranc joint reconstruction.^1,4,7,9–12 Dorsal plates provide rigid fixation without further damage to the articular surfaces of the tarsometatarsal joint. In a 2005 study by Alberta and colleagues, the authors found no significant difference between the transarticular screws and dorsal plating fixation in terms of their ability to realign the first and second tarsometatarsal joints, and maintain alignment during loading.¹⁰ Acting as a buttress, this plating technique helps to resist dorsal dislocation of the metatarsals as well as transverse plane displacement. In the event that a dorsal plate breaks, the fragments are not intra-articular, thereby reducing the chance of joint irritation or destruction. Lastly, dorsal plates with locking screws may provide added stability in cases with high levels of comminution or poor bone stock.¹

Key Pointers On The Surgical Technique

One should perform this procedure with the patient in the supine position under general or spinal anesthesia. Apply a well-padded thigh tourniquet to the operative lower extremity for hemostasis. Prep and drape the surgical extremity from digits to mid-thigh in an aseptic fashion. One may assess the degree of injury to the tarsometatarsal joint by abducting, adducting, pronating and supinating the forefoot on the midfoot under direct visualization with intraoperative image intensification. This may elicit instability about the first tarsometatarsal and intercuneiform joint complex, which may otherwise be difficult to appreciate on static preoperative radiographs.

Using topographic landmarks under image intensification, place a linear incision overlying the second metatarsal and intermediate cuneiform. Carry the incision down through the subcutaneous tissues, being mindful to identify, protect and retract the neurovascular bundle. This approach allows for direct inspection of the first, second and third tarsometatarsal articulations as well as the intercuneiform joints. Inspect the joints to ensure the absence of excessive articular cartilage damage which, if present, may warrant primary arthrodesis. Furthermore, assess the degree of comminution and joint instability. Resect the intervening soft tissue and small avulsion fragments to allow for anatomic reduction to all involved joints about the first, second and third rays.

Perform sequential reduction of the first, second and third tarsometatarsal articulations, and the first, second and third intercuneiform joints. One may accomplish this with the use of a bone clamp along the medial aspect of the first cuneiform and the lateral second metatarsal base. For more severe and unstable injuries, use smooth Kirschner wires for provisional fixation.

Under intraoperative image intensification, verify alignment to ensure anatomic reduction. One may use several relationships between the osseous structures to determine proper anatomic alignment. On the anterior-posterior view, the distance between the first and second metatarsal bases should be less than 3 mm apart, the medial border of the second cuneiform should align with the medial border of the second metatarsal base, and the medial and lateral borders of the first cuneiform should align with their respective borders of the first metatarsal base. On the oblique view, the medial border of the cuboid should align with the medial border of the fourth metatarsal base and the lateral border of the third cuneiform should align with the lateral border of the third metatarsal base. On the lateral view, the metatarsal bases should align directly with their respective tarsal bones.⁶ Pay particular attention to rotational alignment between the metatarsals and their respective cuneiforms.

Then apply an appropriately sized dorsal bridge plate across each of the tarsometatarsal joints. There is a variety of plate options ranging from specialized plating systems to standard small and mini-fragment plates. One may further contour these plates to match the patient’s anatomy. This is generally necessary to avoid plantar tarsometatarsal joint gapping.

Should additional stability be required, one may place a screw from the distal medial aspect of the medial cuneiform and aim toward the plantar half of the second metatarsal base. This will avoid the articular cartilage of the first and second tarsometatarsal joints as well as the articulating cartilage of the first and second cuneiforms. If necessary, for residual intercuneiform instability, one may insert a screw from the medial cuneiform into the intermediate cuneiform. This is ideally positioned distal and plantar to avoid the articular cartilage of the intercuneiform articulation.⁹ The surgeon can capture these screws within the plates or separate them depending on the patient’s particular injury pattern.

During the initial stress examination, instability about the fourth and fifth tarsometatarsal joints may be apparent. Once anatomic alignment of the first three rays occurs, the prior instability about these joints will commonly reduce via ligamentotaxis. Therefore, additional fixation may not be necessary. If gross subluxation or dislocation is apparent about the fourth and fifth metatarsocuboid articulations, one may use percutaneous transarticular smooth K-wires as temporary fixation for a period of four to six weeks, and then remove the wires.

Prior to closure, we recommend placing stress on the tarsometatarsal joint complex under image intensification to verify sound internal fixation and stability of the entire Lisfranc tarsometatarsal joint complex. Copiously irrigate surgical sites and follow this with layered closure. Place the patient in a well-padded sterile dressing from toes to knee with the addition of a posterior splint to maintain the foot at 90 degrees to the lower leg. We recommend that patients remain non-weightbearing until the skin incision has healed. This is followed by a gradual return to full weightbearing and transition to a regular shoe.

What The Research And Surgeon Experience Say About Dorsal Bridge Plating

Despite the lack of robust literature, the existing studies on the use of dorsal plating for the treatment of Lisfranc injuries offer promising results.

A recent prospective study that compared dorsal plating to ORIF with transarticular screw fixation revealed superior outcomes and a lower reoperation rate for patients treated with the plating technique at a two-year follow-up.⁴ Another study involving a small case series of 15 patients demonstrated maintenance of anatomic reduction with the use of dorsal plating during a four-month period prior to scheduled hardware removal.¹² Hsu and coworkers presented a technique guide and revealed no incidence of plate failure in 35 patients over a two-year period.¹³ Although these studies provide encouraging results, there is a clear need for long-term prospective data to better assess outcomes of dorsal plating.

While dorsal plating offers several advantages over other forms of fixation, it is not without inherent limitations. One must contour the plates to each patient’s individual anatomy.¹ This extra step is vital to ensure proper seating of the plate but does require more operating room time.^1,6 Likewise, surgeons cannot place plates percutaneously and thus additional dissection for correct placement is necessary.¹⁰ Despite the added OR time, these additional steps allow for better visualization and provide the opportunity to excise any interposed intra-articular soft tissue and debris while verifying anatomic reduction.

Depending on the plate one uses, hardware prominence may cause soft tissue irritation and may also make closure more challenging.^6,10 By spanning the tarsometatarsal joint, plating systems limit the amount of movement available to the midfoot.¹⁴ Therefore, plating is often temporary and may necessitate future hardware removal. Lastly, with surgical expenses under greater scrutiny, more literature is needed to better study the cost-benefit analysis of these implants.

In Conclusion

While there are several options for treating Lisfranc joint injuries, ORIF with a dorsal bridge plating technique offers the advantage of direct visualization to ensure anatomic reduction. Dorsal plating has become an accepted alternative to the previously described transarticular screw fixation. More specifically, dorsal plating provides rigid stabilization to allow for osteoligamentous healing without additional articular surface destruction of the tarsometatarsal joints. Furthermore, this plating technique helps to resist dorsal and transverse metatarsal displacement. Surgeons can enhance stability with the use of locking screws in the cases with severe comminution or osteopenia. Independent screw placement remains an option as well.

Current literature reveals limited prospective studies demonstrating the efficacy of dorsal plating. However, this technique appears safe and is comparable to other forms of tarsometatarsal joint fixation. Although one cannot reverse damage from the initial injury, by employing the appropriate surgical techniques, the surgeon can limit further destruction and restore anatomic alignment as well as limit iatrogenic damage to the bone, articular cartilage and soft tissue structures.

Dr. Magnus is a second-year podiatric medicine and surgery resident at Gundersen Medical Foundation in La Crosse, Wis.

Dr. Iceman is a second-year podiatric medicine and surgery resident at Gundersen Medical Foundation in La Crosse, Wis.

Dr. Roukis is attending staff in the Orthopaedic Center at the Gundersen Health System in La Crosse, Wisconsin. He is Past President and a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Roukis has disclosed that he is a consultant for DePuy Synthes, FH ORTHO, Integra and Novastep. He receives royalties from CrossRoads Extremity Systems, Novastep and Stryker Orthopaedics.  

References
1.    Kestner C. Open reduction and fixation of unstable Lisfranc injuries using dorsal plates. Tech Foot Ankle Surg. 2015; 14(4):181-187.
2.    Buzzard B, Briggs P. Surgical management of acute tarso metatarsal fracture dislocations in the adult. Clin Orthop Relat Res. 1998; 353:125-133.
3.    Hardcastle P, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarso metatarsal joint- incidence, classification and treatment. J Bone Joint Surg Br. 1982; 64(3):349-356.
4.    Hu SJ, Chang SM, Li XH, Yu GR. Outcome compatison of Lisfranc injuries treated through dorsal plate fixation versus screw fixation. Acta Orop Bras. 2014; 22(6):315-320.
5.    Stavlas P, Roberts C, Xypnitos F, Giannoudis P. The role of reduction and internal fixation of Lisfranc fracture-dislocations: a systematic review of the literature. Int Orthop. 2010; 34(8):1083-1091.
6.    Zgonis T, Roukis T, Polyzois V. Lisfranc fracture-dislocations: current treatment and new surgical approaches. Clin Podiatr Med Surg. 2006; 23(2):303-322.
7.    Purushothaman B, Robinson E, Lakshmanan P, Siddique M. Extra-articular fixation for treatment of Lisfranc injury. Surg Technol Int. 2010; 19:199-202.
8.    Nery C, Raduan F, Baumfeld D. Joint-sparing corrections in malunited Lisfranc joint injuries. Foot Ankle Clin. 2016; 21(1):161-176.
9.    Aronow M. Joint preserving techniques for Lisfranc injury. Tech Orthop. 2011; 26(1):43-49.
10.    Alberta F, Aronow M, Barrero M, Diaz-Doran V, Sullivan R, Adams D. Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. 2005; 26(6):462-473.
11.    Consculluela P, Ebert A, Varner K. Dorsomedial bridge plating of Lisfranc injuries. Tech Foot Ankle Surg. 2009; 8(4):215-220.    
12.    Stern R, Assal M. Dorsal multiple plating without routine transarticular screws for fixation of Lisfranc injury. Orthop. 2014; 37(12):815-819.
13.    Hsu A, Moss L, Harris T. Dorsal plating of low-energy Lisfranc injuries a case report. Foot Ankle Spec. 2014; 8(1):73-76.
14.    Lau S, Howells N, Millar M, De Villiers D, Joseph S, Oppy A. Plates, screws, or combination? Radiologic outcomes after Lisfranc fracture dislocation. J Foot Ankle Surg. 2016; 55(4):799-802.