SLR - May 2016 - Anthony Chesser
Reference: Charlton T, Boe C, Thordarson DB. Suture Button Fixation Treatment of Chronic Lisfranc Injury in Professional Dancers and High-Level Athletes. J Dance Med Sci. 2015 Dec; 19(4):135-9.Scientific Literature Review
Reviewed By: Anthony Chesser, DPM
Residency Program: Western Pennsylvania Foot and Ankle Institute
Podiatric Relevance: There has been a great swing in the past 10 years with treatment of Lisfranc injuries towards rigid fixation. These injuries are often subtle and can be detrimental to our patient population especially the high functioning athlete. These types of individuals typically do not tolerate rigid screw fixation and can impede them from their high level activities such as professional ballet. The authors hypothesis that the suture button device would restore motion at the Lisfranc joint and allow for return to activity without the limitation and complications of rigid fixation.
Methods: Inclusion criteria for this study were professional dancers or high-level (Division I College) athletes who had been diagnosed with Lisfranc injury. These patients had to fail conservative treatment for a minimum of six months. They needed clinically to have pain at the first or second tarsometatarsal joint, and either minimum of 2mm diastasis on weight bearing plain film or suggestive signal changes on MRI.
Operation: Anatomic margins of the cuneiforms and metatarsals were drawn on skin to assist with placement of the incision and the Kirschner wire guide pin. A dorsal 2cm incision was made. Attention was made to avoid the medial dorsal cutaneous nerve. The fascia over the extensor halluces longus and extensor halluces brevis was incised. The neurovascular bundle was protected and the Lisfranc ligament was identified deep to the bundle and assessed for laxity with a Freer elevator. Under fluoroscopic imaging, a 1.6mm Kirschner wires was placed from the medial cuneiform towards the second metatarsal. This was placed slightly distal to avoid the third metatarsal because it can block access to the reverse trajectory.
The medial starting point is between the first tarsometatarsal joint and distal to the tibialis anterior tendon insertion. Once position was confirmed via fluoroscopy a 2.7 cannulated drill was used from medial to lateral direction. A suture lasso was positioned into the drill hole and the suture button was advanced from the second metatarsal into the medial cuneiform. The suture button was tied against the second metatarsal and the direction of the button was chosen so the bulk of the suture was not tied on the surface of the medial cuneiform. Postoperative course was a short leg splint and the patient was kept non-weight bearing for two weeks. The patient was then placed in a CAM walker for gentle activity or passive ankle range of motion. The patients were non-weight bearing for an additional four weeks (six total). They were then placed in a shoe and an arch support and allowed to transition off crutches gradually over the course of two weeks. Dancers were allowed barre work at three months and full activity at six months. The other athletes were low impact at three months and gradual return to full training at six months
Results: The authors treated seven patients (six female and one male) with the suture button device (Arthrex Mini TightRope). Five patients were professional dancers and two were NCAA Division I soccer players. Average age of the patients was 24.6 ranging from 18 to 29 years of age. There was no wound healing problems reported. Preoperative AOFAS midfoot scores were 65 ranging from 59 to 72 and most of their complaints were of moderate pain with activity of daily living. Post-operatively the midfoot AOFAS score was 97 ranging from 90 to 100. All patients returned to full activity and were participating at pre-injury level.
Conclusion: The authors stated that non-rigid fixation, “flexible fixation,” is a viable treatment option for the high level athlete. These seven athletes were able to return to pre-injury level activity. This article is the third case series that describes the suture button for treatment of Lisfranc injuries (Cottom in 2008 JFAS and Brin 2010 in FAI). This treatment is another tool in our arsenal to treat Lisfranc injuries especially in patient populations that require motion across their midfoot.