Mayne Alistair I W, Lawton Robert, Dalgleish Stephen, Harrold Fraser, Chami George
Department of Trauma and Orthopaedic Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, United Kingdom.
Department of Trauma and Orthopaedic Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, United Kingdom.
Injury. 2017 Aug;48(8):1764-1767. doi: 10.1016/j.injury.2017.04.003. Epub 2017 Apr 11.
There is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of the 4th & 5th tarsometatarsal joints is sufficient to stabilise Lisfranc injuries or if fixation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-articular plate which risk causing chondrolysis and/or osteoarthritis. The aims of this cadaveric study were to determine if routine fixation of the 1st and 3rd tarsometatarsal joints is necessary and to determine if a distal to proximal home run screw is adequate.
Using 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displacement at each ray (1st-5th) and 1st-2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability.
At baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st-2nd intermetatarsal gap was 0mm. After transection of the Lisfranc ligament only, there was 1st-2nd intermetatarsal gaping (mean 4.5mm), but no increased dorsal displacement. After additional transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement.
The results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd-4th) are intact, the 3rd ray does not need to be routinely stabilised.
对于将一枚贯穿螺钉（从内侧楔骨至第2跖骨基底）与第4、5跗跖关节的克氏针固定相结合是否足以稳定Lisfranc损伤，或者是否还需要固定第1和第3跗跖关节，目前存在争议。与第2、4和5跗跖关节不同，第1和第3跗跖关节的稳定需要关节内螺钉或关节外钢板，但这有导致软骨溶解和/或骨关节炎的风险。本尸体研究的目的是确定常规固定第1和第3跗跖关节是否必要，以及确定一枚从远至近的贯穿螺钉是否足够。
使用8例经蒂尔防腐处理的标本，在模拟负重过程中，随着韧带依次损伤和固定，测量各跖骨（第1 - 5跖骨）的跗跖关节背侧移位以及第1、2跖骨间隙，以确定解剖结构和固定对稳定性的作用。
基线时，完整标本在模拟负重过程中跗跖关节背侧平均移位（mm）为：第1跖骨：0.14，第2跖骨：0.1，第3跖骨：0，第4跖骨：0，第5跖骨：0.14。第1、2跖骨间间隙为0mm。仅切断Lisfranc韧带后，第1、2跖骨间出现间隙（平均4.5mm），但背侧移位未增加。在切断所有跗跖关节韧带后，所有关节的背侧移位均增加（第1跖骨：4.5，第2跖骨：5.1，第3跖骨：3.6，第4跖骨：2，第5跖骨：1.3）。采用贯穿螺钉及第4、5跖骨克氏针固定几乎消除了所有移位。进一步切断跖骨间韧带后，第3跖骨的平均背侧移位增加至2.5mm。第3跖骨的克氏针固定完全消除了背侧移位。
本尸体研究结果表明，如果跖骨间韧带完整，将内侧楔骨与第2跖骨基底固定并结合第4、5跗跖关节的克氏针固定可稳定第1和第3跗跖关节。因此，在稳定第2和第4/5跗跖关节后应检查第3跗跖关节的稳定性。如果跖骨间韧带（第3、4跖骨间）完整，则第3跖骨无需常规固定。
