Staged Treatment of High Energy Midfoot Fracture Dislocations

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1 552077FAIXXX / Foot & Ankle InternationalKadow et al research-article2014 Article Staged Treatment of High Energy Midfoot Fracture Dislocations Foot & Ankle International 2014, Vol. 35(12) The Author(s) 2014 Reprints and permissions: sagepub.com/journalspermissions.nav DOI: / fai.sagepub.com Tiffany R. Kadow, MD 1, Peter A. Siska, MD 1, Andrew R. Evans, MD 1, Steven S. Sands, DO 2, and Ivan S. Tarkin, MD 1 Abstract Background: Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious. Methods: One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed. Results: The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred. Conclusion: Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients. Level of Evidence: Level III, retrospective comparative study. Keywords: Lisfranc, midfoot, fracture dislocation, crush injury, external fixation Introduction Optimal care for the polytraumatized patient with high energy midfoot fracture/dislocation has yet to be defined. Judgment must be exercised considering both host and local soft tissue conditions to promote best musculoskeletal outcome while avoiding both systemic and local complications. 3,7,16,24,25 Specific circumstances will dictate whether acute surgical reconstruction is appropriate versus a delayed approach. Delayed surgery is indicated when host physiology is not optimal based on the severity of injuries to head, chest, abdomen, and musculoskeletal system. Further, associated severe adjacent soft tissue injury to the foot and ankle is typically an indication to avoid aggressive acute open reconstruction including either ORIF and/or selected fusion. 8,21,23 In these cases, closed reduction and splinting is common practice as a temporizing measure. 1,5,18 However, achieving and/or maintaining an acceptable closed reduction in high energy midfoot fracture dislocation is difficult. As a potential solution, the external fixator has been suggested as a temporizing device, yet the effectiveness of this strategy has not been comprehensively studied. 3 The aim of this report was to determine the feasibility of using the external fixator as a more effective means of temporary stabilization of high energy midfoot fracture/dislocation in the multiply injured patient. Staged care with interval external fixation is a successful established treatment strategy for other high energy periarticular fractures such as the tibial plateau and plafond. 4,9,11,13,17,20,22 In this study, we hypothesized that (1) the fixator could serve as a rigid splint promoting gross skeletal alignment prior to definitive midfoot open reduction and internal fixation (ORIF) and/or selected fusion, (2) optimal alignment would be achievable at the time of definitive reconstruction without wound complication, and (3) the complication rate from the fixator (eg, pin site infection) would be acceptable. 1 Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA 2 Integris Orthopedic Central, Oklahoma City, OK, USA Corresponding Author: Ivan S. Tarkin, MD, Associate Professor, Department of Orthopaedic Surgery, Chief, Division of Orthopaedic Trauma, University of Pittsburgh Medical Center, Kaufmann Building, Suite 911, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA. tarkinis@upmc.edu

2 1288 Foot & Ankle International 35(12) Figure 1. (a) Preoperative severe midfoot injury in polytrauma patient. (b) External fixation on admission indicated to restore gross alignment as delayed open reconstruction warranted due to compromised host physiology and severe associated local soft tissue injury. Methods Our practice of 5 orthopaedic traumatologist subspecialists treated 123 midfoot fracture/dislocations between July 2005 and June A selected group of 18 high energy complex midfoot fracture dislocations were identified that underwent a staged treatment protocol with interval external fixation and delayed ORIF and/or selected fusion (Figure 1). Indications for staged management included (1) the polytrauma patient who could not tolerate lengthy definitive reconstruction secondary to compromised host physiology and/or (2) midfoot fracture/dislocation associated with a severely compromised soft tissue envelope not amenable to a formal surgical approach. Ten men and 8 women with an average age of 43.4 years (range, 21-67) underwent a staged treatment protocol using a temporizing external fixator prior to delayed definitive ORIF and/or selected midfoot fusion. Mechanism of injury included: motor vehicle collision (n = 11), crush injuries (n = 2), high energy fall (n = 4), and an assault (n = 1). All cases managed in a staged fashion had dislocations of Lisfranc joints with differing combinations of other midand forefoot injuries. Injuries studied were closed fractures, yet the soft tissue injury was considered severe in all cases. All fractures were classified as AO-OTA Classification 89-B (midfoot multiple fractures). 12 Additional AO-OTA Classifications were applied for the individual fractures: navicular (83), cuboid (84), cuneiform (85) (medial: 85-1, middle 85-2, lateral 85-3), and metatarsals (87). Fractures that were noncomminuted were classified by A, and comminuted fractures were classified as B. As defined by Myerson et al, 14 6 patients had total incongruity, laterally displacement patterns (all A1); 6 had partial incongruity patterns with 1 medial pattern (B1) and 5 lateral patterns (B2); and 3 patients had total displacement, divergent dislocations (C2). The distribution of injury patterns within the midfoot are as described in Figure 2. These selected patients were taken to the operating room within the first 24 hours after presentation for external fixation placement at 1 of our 2 level 1 trauma centers by 1 of 5 board-certified orthopaedic traumatologists. Unicolumnar (n = 2) or bicolumnar (n = 16) external fixation was performed. Bicolumnar frame placement typically consisted of a transcalcaneal Schanz pin and fixation in both the medial column (first metatarsal) and lateral column (fourth and or fifth metatarsal). A transfixion pin was placed into calcaneus. In the forefoot, metatarsal Schanz pins were placed into the first as well as fourth and/or fifth metatarsals. Reduction was achieved through ligamentotaxis applied through traction on the toes and was enhanced through sequential lengthening through the medial and lateral column frames. Attempt was made to avoid external fixator placement at the site of anticipated surgical incisions at the time of definitive surgery. Patients were maintained in the external fixator for daily evaluation and management of the soft tissue injuries. Patients remained in the external fixator for an average of 21.3 days. Patients were typically discharged from the hospital and returned to clinic for follow-up. Patients were then brought back to surgery on an elective basis once the host physiology and local soft tissue conditions had improved. The external fixator was removed in the operating room. Patients were treated with open reduction and internal fixation (n = 11) or a primary midfoot fusion (n = 7). Digital radiographs/analysis (Stentor Intelligent Informatics, Stentor, San Francisco, CA) was utilized to measure the effectiveness of the temporary external fixator in restoring gross midfoot alignment. Percentage correction was defined as the change from initial to post fixator alignment. One of the contributing surgeons as well as a senior level resident both conducted measurement analysis. Further, rate of anatomic alignment (displacement <1 mm) was calculated at final follow-up after definitive open reconstruction. Lisfranc joint displacement was calculated based on established radiographic criteria using anteroposterior (AP), oblique, and lateral plain films. 10,15 In order to account for concomitant injury to the midtarsal bones/ joints, foot length was measured to determine utility of staged ORIF or fusion. Statistical analysis was performed with an unpaired, 2-tailed Student t test to statistically compare the improvement between the alignment at initial presentation and after the application of the external fixator. Results After external fixator placement, patients achieved improved gross alignment at all midfoot joints as follows: first/medial cuneiform: 73.6% (P =.0002), second/middle

3 Kadow et al 1289 Navicular Cuboid Medial Cuneiform Middle Cuneiform Lateral Cuneiform 1st Ray 2nd Ray 3rd Ray 4th Ray 5th Ray Pt # 83-A/B 84-A/B 85-A/B1 85-A/B2 85-A/B3 AO - 87 AO - 87 AO - 87 AO - 87 AO B 85-A2 85-B3 87-B 87-B 2 84-A 85B1 85-A2 85-A3 87-B 87-B 87-B 87-B 3 84-B 85-B1 85-B2 85-B3 87-A 87-A 87-A 87-A 4 87-B 87-B 87-B 87-B 87-B 5 85-B2 87-A 87-B 6 84-B 85-B1 85-A2 87-A 87-B 87-B 87-B 7 84-B 85-B1 85-B2 85-B3 87-A 87-A 87-A 8 84-A 85-B1 85-B3 87-B 87-A 87-A 87-A 87-A 9 84-B 85-B2 85-B3 87-B 87-B B1 85-B2 87-A 87-A 87-A B1 85-B2 85-B3 87-B 87-A B1 85-B2 85-B3 87-B 87-B 87-B A 85-B1 85-B1 87-B A 85-B1 85-A2 87-A 87-B B 84-B 85-B1 87-A 87-A 87-A 87-A A 84-B 85-B1 85-B2 85-B3 87-A 87-A 87-A B1 85-B2 85-B3 87-B 87-B B 84-B 850B1 85-B2 85-B3 87-B 87-B 87-B 87-A Figure 2. AO-OTA Classification for individual fractures found in each polytrauma patient selected for interval treatment with an external fixator. cuneiform: 64.8% (P =.0004), third/lateral cuneiform: 53.1% (P =.001), fourth/cuboid: 65.8% (P =.0001), sagittal alignment: 44.2% (P =.02), and restoration of length: 92.6% (P =.0001) (Figure 3). The change in alignment in all areas of assessment was statistically significant. Patients were discharged from the hospital when medically ready and returned to the clinic for wound monitoring and determination of timing for their definitive procedure. This procedure was then scheduled on an elective basis. Patients stayed in the external fixator for an average 21.3 days (range, 7-144). Seven patients underwent primary fusion, and 11 patients had open reduction internal fixation. Alignment achieved at definitive operation was determined to be anatomic (displacement <1 mm) in all patients. No patients developed deep infection after their definitive surgery with the staged protocol. Complications included unacceptable deformity after external fixator placement requiring prompt revision due to skin tenting in 1 patient. On postoperative day 3, this patient was taken back to the operating theatre for definitive early surgery as the temporizing frame was ineffective. Pin site infection occurred in another patient, which resolved uneventfully after pin removal and antibiotic treatment prior to definitive fixation. Lastly, 1 patient had symptomatic hardware after healing of the midfoot injury, prompting late hardware removal. Patients were followed for an average of 440 days. Discussion The purpose of this study was to determine the safety and efficacy of a staged protocol for high energy midfoot fracture/dislocation in the polytraumatized patient. Study results suggest that interval usage of an external fixator restores gross skeletal alignment. More important, however, delayed reconstruction after host and local physiology was optimized yielded good results in terms of final alignment. Further, adherence to a staged protocol for severe midfoot injury in the multiply injured patient avoided wound complication and infection that plague acute surgical reconstruction. Staged reconstruction of high energy periarticular fractures in the polytraumatized patient is a central tenet of damage control orthopedics. 16 This strategy has been popularized for other injury patterns including fractures of the tibial plateau and plafond. 4,9,11,13,17,20,22 Benefits of this approach are both systemic and local. Lengthy reconstructions are typically avoided in the acute phase of injury to avoid systemic complication. Locally, the traumatized soft tissue envelope associated with periarticular fracture is not amenable to superimposed surgical exposure, reduction, and instrumentation without a heightened risk of wound complication and infection. Although splinting of high energy midfoot fracture dislocation is a popular temporizing practice, delayed open reconstruction is more challenging. 1,3,5,18 Typically, optimal alignment is not initially achieved and/or maintained.

4 1290 Foot & Ankle International 35(12) Figure 3. Improvement after placement of external fixator. Further, with increasing time from injury to definitive management, achieving optimal alignment becomes increasingly more challenging. As the soft tissue envelope matures, dense scar and contracture of soft tissues often preclude precise reduction of midfoot fracture and joint dislocations. As a paradigm shift, we have demonstrated a clinically and statistically significant improvement in length and alignment with the application of interval external fixation for complex midfoot injuries. Fixator application is rapid and suitable for the selected polytrauma patient. Although we prefer acute total care when feasible, staged management is appropriate when either the soft tissue envelope is severely traumatized or when the sick trauma patient cannot tolerate a prolonged definitive reconstruction. At our institution, this staged approach is utilized in approximately 15% of cases. The improvement in alignment of border rays is superior compared to the middle rays. These findings are not unexpected considering that the fixator is typically applied with direct distraction to the border rays with indirect reduction via ligamentotaxis to the middle rays. The variable amount of soft tissue disruption to the intermetatarsal structures therefore would predict quality of reduction to the middle rays. By improving skeletal alignment and providing stability, use of the interval external fixation device may stop the cycle of ongoing injury to muscle, tendon, cartilage, and bone. Potentially more critical in the acute phase, vascular and neurologic embarrassment is minimized. Traveling traction promotes effective healing of the traumatized soft tissue sleeve as well. 23 The temptation for ill-advised early surgical reconstruction of midfoot fracture dislocation is diminished when gross skeletal alignment is achieved with a fixator. This approach allows the surgeon to be more thoughtful for the preferred timing of definitive reduction once the host physiology and local soft tissue conditions are optimized. Early definitive treatment with minimally invasive approaches such as limited incisions and percutaneous fixation have significant complications including nonunion and deformity, which can compromise long-term outcomes. 6,15 However, usage of transarticular K-wires as a temporizing measure in cases that cannot be sufficiently maintained in an external fixator alone may be appropriate in selected cases. 2,10 External fixation has been reported as a primary or temporary modality for severe midfoot injury. 10,15,19 Nithyananth et al 15 studied 13 patients with high energy open Lisfranc fracture dislocations. Beyond open fracture care and coverage procedure, open reduction and K-wire fixation was the primary modality for realignment and stabilization. An external fixator was used for added construct rigidity in 4 of 13 cases. Nonanatomic reconstruction with this technique occurred in 38% of cases. Functional outcomes according to the AOFAS system were considered fair or poor in approximately a third of patients. Kuo et al 10 utilized the principle of delayed internal fixation in the setting of severe adjacent soft tissue injury associated with Lisfranc injury. In their study group of 48 patients, 33 were considered high energy injuries and 23 patients were multiply injured. They reported usage of a temporary external fixator in an unspecified number of open injuries prior to definitive care with ORIF. No wound-related complications or deep infections were reported. Despite the safety and efficacy of the staged approach to severe midfoot injury in the polytraumatized patient reported in our study, we do appreciate limitations of this strategy and this report. Validated outcome measures were not reported. However, in all cases anatomic reduction was achieved and no major complications were documented. Quality of reduction is a well-established determinant of treatment success with severe midfoot injuries. 3,10,24-26 Further, selection bias needs to be highlighted as a study limitation as well. Considering the retrospective nature of our study, we do not have precise information on intent to treat. For instance, in 1 case in our series, the fixator was ineffective in maintaining adequate alignment, causing a change in the management plan on postoperative day 3. In cases that an external fixator was not effective for restoring gross alignment for staged care intraoperatively, our standard practice would include limited or formal open reconstruction acutely. In conclusion, staged care of the severely injured midfoot in the polytraumatized patient should be incorporated as an accepted care paradigm. In many cases an external fixator can restore length and gross skeletal alignment, allowing for a delayed definitive reconstruction once host and local physiology are optimized. This protocol lends optimal outcomes through anatomic foot reconstruction while avoiding wound-related complication associated with acute surgery that often is a precursor to septic complication. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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