Modified Dorsal Approach in the Management of Lisfranc Injuries

Background: Open reduction and internal fixation of Lisfranc injuries has typically used multiple longitudinal incisions or a single transverse incision to approach the tarso-metatarsal joint (TMTJ). The incidence of wound-related complications is considerable. We describe a novel single-incision approach that utilizes subcutaneous windows to the medial TMTJ. Methods: A retrospective review identified 150 patients who underwent open reduction and internal fixation for Lisfranc injuries, via the modified dorsal approach, at our center between January 2011 and June 2016. Removal of hardware (ROH) was routinely undertaken in 105 patients at a median of 210 days postoperatively. Medical records were reviewed to record patient demographics, mechanism of injury, and operative details. Outpatient notes were reviewed to identify wound-related complications, including delayed wound healing, superficial infection, wound dehiscence, deep infection, complex regional pain syndrome (CRPS), neuroma, and impaired sensation. Median age was 37 years (range, 19-78 years). Seventy-three percent of patients (110) were male. Most frequent mechanisms of injury were motor vehicle accident (MVA), 39%; motorbike accident (MBA), 19%; and fall, 18%. Sixteen percent (24) of injuries were open. Five patients required soft tissue reconstruction at the primary operation. Median follow-up was 144 (range, 27-306) weeks. Results: Following the primary procedure, 14% of patients experienced wound-related complications including delayed healing (3%), superficial infection (5%), dehiscence (3%), complex regional pain syndrome (CRPS) (1%), and impaired sensation (1%). MBA injuries were at 15.1 times odds of superficial infection (P =.01) than were MVA injuries. Following ROH, 13% of patients experienced wound-related complications, including delayed healing (2%), superficial infection (8%), dehiscence (1%), CRPS (2%), and neuroma (1%). Overall, 5 patients returned to surgery for soft tissue reconstruction for wound dehiscence. Conclusion: The modified dorsal approach using intervals to the midfoot offers a viable alternative with comparable wound complication rates to existing midfoot approaches. Level of Evidence: Level IV, case series.