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MINERVA ORTOPEDICA E TRAUMATOLOGICA
A Journal on Orthopedics and Traumatology
Minerva Ortopedica e Traumatologica 2008 June;59(3):179-91
Lisfranc fracture-dislocation: update on classification, diagnosis and treatment
Fino A., Torasso G., Valente A., Sabatini L., Trecci A., Uslenghi M.
Clinica Ortopedica S. Luigi di Orbassano, Torino, Italia
The tarsometatarsal fracture-dislocations are relatively rare, they represent about 0.2% of all fractures, with an incidence of 1 case/50 000/year. The traumatic mechanism is often difficult to assess, because carriers of the involved forces have different direction and intensity and are differently confined over time, as they depend on the multiplicity of traumatic circumstances. Among the numerous proposal classifications in the Literature the anatomical one is the most intuitive and the easiest to apply clinically; in most of the studies reported, there is no relationship between causal mechanism, anatomical appearance, radiological appearance and effective prognostic value. The complexity of the mechanisms of Lisfranc injuries requires careful research of associated primary and secondary lesions. The traditional radiology, with simple antero-posterior, lateral and 30 ° oblique projections, allows to document the most severe dislocations. Often, however, it does not detect small lesions; in these cases it is, therefore, necessary to use a more accurate radiographic tool, represented by computed tomography or magnetic resonance imaging. The first allows to evaluate with accuracy the degree of articular diastasis, while the second allows an accurate reconstruction of Lisfranc ligament. The bloodless treatment with plaster cast apparatus is today performed only in cases of minor ligamentous segments injury, with stable articular segments, in which an external reduction maneuver is not necessary. In order to obtain a reduction of the anatomic lesion other authors propose setting with K percutaneous wires. In Literature the need of open-air treatments with internal unstable injury synthesis is increasingly more accredited: direct visualization of the articulation allows a reliable reduction with an anatomic synthesis of larger fragments and the removal of the smallest ones. The anatomical reduction is not applicable only in case of crushing injuries severely comminute. The more appropriate fixing method to be used is still debated. The choice is among K wires, AO cortical screws, cannulate bolts, spongiosa screws, PLLA bolts resorbable. Finally, some authors, especially French, recommend the primary arthrodesis in situ to treat the complex pluriframmentary injuries; this method, however, presents many technical problems in acute, for individual metatarsus are very difficult to be positioned properly.