Management of Lisfranc Injury with Anterolateral Calcaneal Compression Fracture
Lisfranc injuries are complex and often result from high-energy trauma, leading to fractures or dislocations of the midfoot complex. One specific pattern of injury involves the lateral column of the Lisfranc joint, particularly the cuboid, due to abduction forces. However, injuries involving the anterolateral calcaneus are less common and frequently overlooked. This oversight can lead to delayed surgical management, chronic foot deformities, and functional disabilities. This article discusses the management of Lisfranc injuries with anterolateral calcaneal compression fractures, focusing on diagnosis, treatment strategies, and clinical outcomes.
The mechanism of Lisfranc injuries is multifaceted, often resulting in various fracture patterns or dislocations. Abduction force injuries, in particular, can cause fractures or dislocations of the lateral column of the Lisfranc joint, especially the cuboid. However, the involvement of the anterolateral calcaneus is less frequently observed. The calcaneocuboid (CC) joint facet fragment is often too inconspicuous to be detected on plain X-rays, and surgeons typically focus on the Lisfranc joint, leading to missed diagnoses of anterolateral calcaneal compression fractures and even Chopart joint injuries. This can result in delayed treatment and long-term complications.
The treatment of this specific injury pattern is challenging and has been rarely reported in the literature. One case reported by Gajendran et al. involved a nutcracker fracture of the anterolateral calcaneus and navicular, which resulted in compromised outcomes with conservative treatment. The key challenge in managing lateral column injuries is the reduction and fixation of the small, compressed, and sometimes comminuted facet fragment. The authors hypothesized that using a mini-fragment plate for rafting fixation could achieve stable fixation and acceptable clinical outcomes for this injury pattern.
In this study, 13 patients with Lisfranc injuries and anterolateral calcaneal compression fractures were enrolled. Initial X-rays missed calcaneal involvement in 38.5% of cases (5/13). After thorough evaluation, all patients underwent open reduction and internal fixation (ORIF) once the soft tissue condition improved. The mean follow-up period was 27.69 ± 14.41 months (range: 12–60 months). Two patients experienced early soft-tissue complications, which were managed conservatively. Plain radiographs confirmed bony union in all patients by the third postoperative month.
The Visual Analogue Scale (VAS) scores significantly improved from 5.9 ± 1.3 preoperatively to 1.8 ± 1.4 at the final follow-up (t = 17.05, P < 0.05). The final American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score was 82.1 ± 10.9 (range: 56.0–97.0). All patients returned to work at an average of 7.5 ± 2.2 months postoperatively (range: 5–12 months). The symptoms and AOFAS midfoot scores correlated with the time of returning to work (r = 0.744 and 0.871, respectively, P < 0.05).
Implant removal was performed in 12 cases at an average of 11 months postoperatively (range: 8–14 months). Three cases showed implant breakage during removal, but no symptoms were reported. Two patients (15.4%) developed posttraumatic arthritis of the Lisfranc joint, which was managed with analgesic medication and orthosis support. Three patients (23.1%) complained of midfoot rigidity. No cases of nonunion, malunion, or midfoot deformity were observed during follow-up.
The most common pattern of lateral column compression fracture is the “nutcracker fracture” of the cuboid, which can cause lateral column shortening and forefoot deformity with a high complication rate. However, injuries involving both the Chopart and Lisfranc joints are rare. Ponkilainen et al. reported that only 5.8% of midfoot injuries involved both joints. The exact mechanism of this fracture pattern remains unclear, but abduction forces are believed to play a significant role. The calcaneal compression fracture is often missed, and misdiagnosis or improper management can lead to posttraumatic arthritis and functional limitations. Diagnosis from X-rays can be challenging, and in this study, 38.5% of anterolateral calcaneal fractures were initially missed. Surgeons tend to focus on the Lisfranc joint, potentially overlooking Chopart joint involvement. Detailed physical examination is crucial to avoid misdiagnosis. Anterolateral calcaneal fractures should be suspected if tenderness is detected on the lateral side of the foot. Additionally, the fragment may be too small to be visible on plain X-rays. Therefore, three-dimensional computed tomography (3D-CT) scanning is recommended for evaluating midfoot injuries.
The primary goal in managing midfoot complex injuries is the anatomical restoration of midfoot alignment and facet with stable fixation. Reduction and fixation of the Lisfranc joint are typically performed first. Although primary arthrodesis is recommended for ligamentous Lisfranc injuries, the authors prefer ORIF to prevent early degeneration of adjacent joints. Patients in the study had a low acceptance level of primary arthrodesis. Managing anterolateral calcaneal compression fractures is challenging due to the small and comminuted nature of the facet fragments. Dhillon et al. reported acceptable outcomes in three cases of crush fractures of the anterior end of the calcaneus using K-wires and a fixator to restore lateral column length. However, K-wire fixation or a fixator may not provide sufficient stability and can cause soft tissue problems, such as pin tract infection. Screw fixation is an alternative for small fragments, but it may fail if the fragment is too small, comminuted, or if the patient has osteoporosis. The authors prefer using a mini-fragment plate system, which offers several advantages. Rafting fixation along the CC joint provides rigid support to prevent fragment redisplacement. The compression effect of the plate stabilizes the fragment without requiring screw fixation into the fragment, limiting displacement. No cases of implant failure or fragment redisplacement occurred in the study. Plate fixation also facilitates future implant removal. The authors achieved satisfactory outcomes with anatomical reduction and stable fixation. The average VAS score significantly improved, and most patients achieved good to excellent AOFAS midfoot scores. All patients returned to work within an average of 7.5 months postoperatively. Limited symptoms and satisfactory AOFAS scores correlated with shorter return-to-work times.
Complications remain a concern in midfoot injuries. Despite proper treatment, the postoperative complication rate for Lisfranc complex injuries is relatively high due to high-energy trauma. In this study, two cases (15.4%) of three-column Lisfranc complex injuries developed posttraumatic arthritis, which was managed conservatively. Implant removal timing is another consideration. Early removal may cause midfoot instability, while prolonged fixation may result in rigid joints similar to arthrodesis. Three patients who removed implants after 12 months complained of midfoot rigidity. Implant breakage was observed in three cases removed after 10 months, but no symptoms were reported. The authors recommend removing Lisfranc and intercuneiform screws before full weight-bearing and performing the final removal procedure before 10 months. The optimal timing for implant removal remains unclear and requires further study.
This study has several limitations. The sample size was small due to the rarity of this injury pattern. No comparative analysis was performed, and the evaluation was not comprehensive. Long-term clinical outcomes remain uncertain. The current classification system for tarsometatarsal joint disruption is simple and precise but limited to Lisfranc injuries. Whether this system can be extended to midfoot complex injuries involving the Chopart joint requires further discussion. The authors aim to modify the classification system based on cadaver anatomy research and biomechanical studies. The detailed mechanism of this injury pattern is still unknown and requires further investigation.
In conclusion, Lisfranc injuries with anterolateral calcaneal compression fractures are uncommon and often misdiagnosed. Thorough evaluation of the entire midfoot complex, including both Lisfranc and Chopart joints, is essential. ORIF remains the gold standard for this injury pattern, and acceptable clinical outcomes can be achieved with proper management.
doi.org/10.1097/CM9.0000000000001924
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