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Screw Fixation Compared with Suture-Button Fixation of Isolated Lisfranc Ligament Injuries
Vinod K. Panchbhavi, MD, FRCS1; Santaram Vallurupalli, MD1; Jinping Yang, MD1; Clark R. Andersen, BS1
1 The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0165. E-mail address for V.K. Panchbhavi: vkpanchb@utmb.edu. E-mail address for S. Vallurupalli: santaramv@gmail.com. E-mail address for J. Yang: jyang@utmb.edu. E-mail address for C.R. Andersen: clanders@utmb.edu
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Arthrex, Inc. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery and Rehabilitation, The University of Texas Medical Branch, Galveston, Texas

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 May 01;91(5):1143-1148. doi: 10.2106/JBJS.H.00162
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Abstract

Background: A cannulated screw is currently used to reduce and stabilize diastasis at the Lisfranc joint. The screw requires removal and may break in situ. A suture button does not have these disadvantages, but it is not known if it can provide stability similar to that provided by a cannulated screw or an intact Lisfranc ligament. The objective of the present study was to compare the stability provided by a suture button with that provided by a screw when used to stabilize the diastasis associated with Lisfranc ligament injury.

Methods: Fourteen fresh-frozen, paired cadaveric feet were dissected to expose the dorsal region. A registration marker triad consisting of three screws was fixed to the first cuneiform and the second metatarsal. A digitizer was utilized to record the three-dimensional positions of the registration markers and their displacement in test conditions before and after cutting of the Lisfranc ligament and after stabilization of the joint with either a suture button or a cannulated screw. The first and second cuneiforms and their metatarsals were removed, and the ligament attachment sites were digitized. Displacement at the Lisfranc ligament and the three-dimensional positions of the bones were determined.

Results: Loading with the Lisfranc ligament cut resulted in displacement that was significantly different from that after screw fixation (p = 0.0001), with a difference between means of 1.2 mm. Likewise, loading with the Lisfranc ligament cut resulted in a displacement that was significantly different from that after suture-button fixation (p = 0.0008), with a difference between means of 1.00 mm. No significant difference in displacement was found between specimens fixed with the suture button and those fixed with the screw.

Conclusions: Suture-button fixation can provide stability similar to that provided by screw fixation in cadaver specimens after isolated transection of the Lisfranc ligament.

Clinical Relevance: Fixation with a suture button may be an acceptable alternative to screw fixation in the treatment of isolated Lisfranc ligament injuries, avoiding subsequent surgery to remove the hardware prior to weight-bearing.

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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Vinod K. Panchbhavi, MD, FRCS
    Posted on May 28, 2009
    Dr. Panchbhavi and Mr. Andersen respond to Dr. Rogers and Mr. Emeagi
    University of Texas Medical Branch, Galveston, Texas

    We thank Dr. Rogers and Mr.Emeagi for their interest in our work. The following are our responses to the points raised:

    1. We agree that PMMA in the tibia can alter the tibia’s mechanical properties. However, this is not pertinent to our study, whose area of interest, the Lisfranc joint, lies far from the tibia. Testing the effects of loading was standardized in all specimens, and the MTS machine and the PMMA in the tibia were merely means to replicate body weight.

    2. Current practice when treating a Lisfranc ligament injury is to immobilize the foot for three months in a non-weight-bearing cast after screw fixation of the Lisfranc joint. It is hoped that the Lisfranc ligament heals by three months, after which the screw is taken out, and only then walking, weight bearing, and cyclic loading are allowed. As noted in our article, after the three-month period, if the Lisfranc ligament does not reconstitute itself it is hoped that the suture-button may help support the Lisfranc joint. The objective in our study was strictly defined to first compare the strength of fixation achieved by a screw (the current standard of practice) to that of a suture-button. Testing cyclic loading and the endurance limit is our objective for future studies.

    3. Technical feasibility limits the use of the suture-button to repairing the diastasis due to ligamentous disruption between the medial cuneiform and the base of the second metatarsal bones. For example, a suture-button cannot be used to stabilize associated fractures such as those in the bases of the metatarsals or disruption of the first metatarso-cuneiform joint.

    4. We feel that further cadaver and clinical studies are necessary to evaluate the use of the suture-button technique in Lisfranc injuries. We would like to take this opportunity to reemphasize that we do not advocate any clinical use or extrapolation based on this study. The implication of this study is that the suture-button technique in the future may prove to be an acceptable alternative to a screw in stabilizing Lisfranc injury.

    5. We agree that the age group of the specimens is not representative, as these injuries usually occur in younger patients. However, younger-age specimens are harder to obtain and were not necessary for this study as the right and left sides of the same cadaver served to standardize the methods used.

    Benedict A. Rogers
    Posted on May 25, 2009
    Suture-Button Fixation of Isolated Lisfranc Injuries
    South West Thams, London, England

    To the Editor:

    We read with interest the article by Panchbhavi et al. (1) and would like to make the following points:

    1. The tibial intramedullary canal was filled with polymethylmethacrylate (PMMA) prior to the loading protocol. It is known from spinal studies that PMMA significantly alters the biomechanical properties of bone (2). Do the authors know how their tibial model compares with the normal physiological stresses?

    2. Cyclical loading has been shown to more accurately recreate the loads that are transmitted through the foot (3). Have the authors any indication as to the response of the suture button technique, such as the endurance limit, when exposed to repetitive stresses of Lisfranc joint?

    3. Myerson described that different types of Lisfranc injury (4) result from different force vectors and require different surgical techniques (5).Did this study take into account the different types of Lisfranc injuries and is the suture button technique suitable for all types of injury?

    4. The implication of this study to clinical practice is unclear. Numerous techniques have been documented regarding the stabilization of these injuries (6,7) not all of which have been considered in this study.

    5. The mean age of tibial/foot specimens used was 80 years, suggesting that the specimens had reduced intrinsic ligament strength. Extrapolating this cadaveric study to the treatment of these injuries, that are commonly seen in a younger population, must be done with caution.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Panchbhavi VK, Vallurupalli S, Yang J, Andersen CR. Screw fixation compared with suture-button fixation of isolated Lisfranc ligament injuries. J Bone Joint Surg Am. 2009;91:1143-8.

    2. Gilbert JL, Ney DS, Lautenschlager EP. Self-reinforced composite poly(methyl methacrylate): static and fatigue properties. Biomaterials. 1995;16:1043-55.

    3. Daniels TR, Lau JT, Hearn TC. The effects of foot position and load on tibial nerve tension. Foot Ankle Int. 1998;19:73-8.

    4. Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989;20:655-64.

    5. Rajapakse B, Edwards A, Hong T. A single surgeon's experience of treatment of Lisfranc joint injuries. Injury. 2006;37:914-21.

    6. Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ. Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. 2005;26:462-73.

    7. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986;6:225-42.

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