1Service d'Orthopédie-Traumatologie, Hôpital Nord, Place Victor Pauchet, F 80054 Amiens Cedex 1
Les auteurs rapportent une étude de 69 fractures luxations de Lisfranc. Ces fractures sont survenues au cours d’accidents violents.
Selon ia classification de Trillat nous avons 19 fractures luxations homolatérales spatulaires, 22 homolatérales columno-spatulaires, 8 divergentes columnaires et 19 divergentes columno spatulaires. Une luxation a été réduite en urgence avant la radiographie et ne peut étre classée.
Le traitement était une réduction orthopédique et plétre 5 fois, brochage percutané 2 fois, reposition arthrodése 5 fois, réduction sanglante avec brochage 55 fois. Deux cas étaient non traités car méconnus.
Il a été réalisé repositions arthrodéses secondaires é la suite des échecs des méthodes précédentes. Elles ont été réalisées de 9 mois é 5 ans aprés le traumatisme initial pour ankylose douloureuse en mauvaise position ou arthrose. Elles étaient totales 6 fois, partielles externes 2 fois, partielles internes 3 fois.
L’étude des résultats montre faut réduire les luxations fractures tarso-métatarsiennes méme si le déplacement est minime et les fixer. Le moyen le plus satisfaisant semble étre la réduction sanglante s’il existe le moindre défaut anatomique. La reposition arthrodése totale d’embIée est indiquée lorsqu’il existe une comminution importante de l’interligne articulaire. Si la reposition arthrodése secondaire totale donne de bons résultats, sa réalisation est parfois difficile. Les arthrodéses partielles externes doivent étre abandonnées car elles ne semblent pas logiques. L’arthrodése partielle interne»n’a pas prouvé sa supériorité par rapport à l'arthrodèse totale.
Purpose of the Study: Classicaly Lisfranc fractures dislocations are unusual. Our study is based on 69 observations from January 1974 to January 1992.
Material and Methods: Fractures occured during tremendous impacts with a sex ratio of two men for one woman. The authors insist on the diagnostic value of good quality standard x-rays. Using Trillat's classification, we had 19 homolateral spatular fractures dislocations, 22 homolateral columno-spatular, 8 divergent columnar and 19 divergent columno spatular. A dislocation was reduced in emergency before radiography. The treatment consisted in orthopedic reduction and plaster 7 times, percutaneous kwire 2 times, immediate arthrodesis 5 times, open reduction and internal fixation with kwires 55 times. Post-operatively, 8 complications were noticed. 11 secondary arthrodesis were made with reference to failures of previous methods. They have been performed from 9 months to 5 years after the initial traumatism due to a painful ankylosis in bad position or arthrosis. The arthrodesis was total 6 times, partial lateral 2 times, partial medial 3 times.
Results: 63 patients were reviewed with a minimum follow-up evaluation of two years and a maximum of 9 years. The results show that we must reduce the tarsometatarsal fracture dislocations even if the displacement is minimal and we must fix them. The most satisfactory means seem to be open reduction if the least anatomical defect exists. Immediate, total arthrodesis reposition is suitable when an important articular comminution exists. If the total secondary arthrodesis reposition gives good results, its realization is sometimes difficult. The lateral partial arthrodesis must be discontinued, because they don't seem logical. The medial partial arthrodesis didn't prove its superiority, compared with total arthrodesis.
Discussion: The reduction of Lisfranc's dislocation is essential. The single case not unreduced has given a bad result as shown in the litterature. When the orthopedic treatment is well-made, the result is good. The open reduction followed by an axial fixation has only given 56 per cent of good results. The main reason of these bad results is an important comminution which should have practised an immediate arthrodesis reposition and a bad reduction. We must be aware on the quality of the anatomical reduction. The secondary arthrosis appeared principally in cases where the reduction was defective (13 observations out of 50). The 5 immediate arthrodesis have all given a good result.
Conclusion: The retrospective study of the series teaches us to reduce the tarsometatarsal fractures dislocations even if the displacement is minimal and to fix them. We must make a wider place to the immediate arthrodesis reposition.