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Biomechanical Comparison of Fixation Stability Using a Lisfranc Plate

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Biomechanical Comparison of Fixation Stability Using a Lisfranc Plate Foot and Ankle Surgery 25 (2019) 71–78 Contents lists available at ScienceDirect Foot and Ankle Surgery journa l homepage: www.elsevier.com/locate/fas Biomechanical comparison of fixation stability using a Lisfranc plate $ versus transarticular screws a,b a,c, d d Nathan C. Ho , Sophia N. Sangiorgio *, Spenser Cassinelli , Stephen Shymon , d a,b a,c d John Fleming , Virat Agrawal , Edward Ebramzadeh , Thomas G. Harris a The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center, Orthopaedic Institute for Children, in Alliance with UCLA, 403 W. Adams Blvd., Los Angeles, CA 90007, United States b University of Southern California Department of Biomedical Engineering, Los Angeles, CA, United States c University of California, Los Angeles Department of Orthopaedic Surgery, Los Angeles, CA, United States d Los Angeles County Harbor—UCLA Medical Center, Los Angeles, CA, United States A R T I C L E I N F O A B S T R A C T Article history: Background: To obtain adequate fixation in treating Lisfranc soft tissue injuries, the joint is commonly Received 3 March 2017 stabilized using multiple transarticular screws; however iatrogenic injury is a concern. Alternatively, two Received in revised form 28 July 2017 parallel, longitudinally placed plates, can be used to stabilize the 1st and 2nd tarsometatarsal joints; Accepted 8 August 2017 however this may not provide adequate stability along the Lisfranc ligament. Several biomechanical studies have comparedearliermethodsoffixation using platestothestandardtransarticularscrew fixationmethod, Keywords: highlighting the potential issue of transverse stability using plates. A novel dorsal plate is introduced, Lisfranc injury intended to provide transverse and longitudinal stability, without injury to the articular cartilage. Plate Methods: A biomechanical cadaver model was developed to compare the fixation stability of a novel Fixation fi Biomechanics Lisfranc plate to that of traditional xation, using transarticular screws. Thirteen pairs of cadaveric specimens were tested intact, after a simulated Lisfranc injury, and then following implant fixation, using one method of fixation randomly assigned, on either side of each pair. Optical motion tracking was used to measure the motion between each of the following four bones: 1st metatarsal, 2nd metatarsal, 1st cuneiform, and 2nd cuneiform. Testing included both cyclic abduction loading and cyclic axial loading. Results: Both the Lisfranc plate and screw fixation method provided stability such that the average 3D motions across the Lisfranc joint (between 2nd metatarsal and 1st cuneiform), were between 0.2 and 0.4 mm under cyclic abduction loading, and between 0.4 and 0.5 mm under cyclic axial loading. Comparing the stabilityof fixation betweenthe Lisfrancplateand thescrews,thedifferencesinmotionwere all 0.3 mm or lower, with no clinically significant differences (p > 0.16). Conclusions: Diastasis at the Lisfranc joint following fixation with a novel plate or transarticular screw fixation were comparable. Therefore, the Lisfranc plate may provide adequate support without risk of iatrogenic injury to the articular cartilage. © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. 1. Introduction range from low energy falls to high energy crushes such as automobile accidents [1–4]. Depending on the type of impact, the Lisfranc injuries have been reported at a rate of approximately injury may result in anything from small bone avulsion fractures to 1 per 55,000 people per year [1]. Injury to the Lisfranc joint can complete ligament ruptures and midfoot dislocations [5]. If misdiagnosed or left untreated, Lisfranc injuries may lead to a progressive flatfoot deformity or midfoot instability, along with $ symptomatic osteoarthritis in the future [5]. Study conducted at: The J. Vernon Luck, Sr., M.D. Orthopaedic Research Center Successful treatment of Lisfranc injuries requires sufficient Orthopaedic Institute for Children, in Alliance with UCLA. * Corresponding author at: University of California, Los Angeles Department of stabilization and fixation of the joint space. Open reduction and Orthopaedic Surgery, Los Angeles, CA, United States. internal fixation (ORIF) or arthrodesis of the Lisfranc joint has been E-mail addresses: [email protected] (S.N. Sangiorgio), found to be essential in treating a Lisfranc injury [6,7]. To obtain [email protected] (S. Cassinelli), [email protected] (S. Shymon), adequate fixation for an ORIF, the joint is commonly stabilized jffl[email protected] (J. Fleming), [email protected] (V. Agrawal), [email protected] (E. Ebramzadeh), [email protected] using multiple transarticular screws, allowing for reduction and (T.G. Harris). http://dx.doi.org/10.1016/j.fas.2017.08.004 1268-7731/© 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved. 72 N.C. Ho et al. / Foot and Ankle Surgery 25 (2019) 71–78 presumed ligament repair; however iatrogenic injury to the the hindfoot a second screw was inserted through the navicular articular surfaces is a concern with this method. Alternatively, and calcaneus (Fig. 1). two parallel, longitudinally placed plates can be used to stabilize For each specimen the Lisfranc joint space was exposed without the 1st and 2nd tarsometatarsal joints [8]; however this method disrupting the ligaments, muscles, or tendons, so that motion may not provide adequate stability in the transverse plane or along tracker flags could be secured to each of the four bones: 1st the Lisfranc ligament. Several biomechanical studies have com- metatarsal, 2nd metatarsal, 1st cuneiform, and 2nd cuneiform. pared earlier methods of fixation using plates to the standard transarticular screw fixation method, highlighting the potential 2.2. Biomechanical loading issue of transverse instability using plates [8–10]. To address shortcomings of both plates and transarticular screws, a novel Previous studies using cadaver models have fixed the hindfoot dorsal plate has been developed that is intended to provide in 30 of plantarflexion, with the goal of maximizing the strain on transverse as well as longitudinal stability, without risk of injury to the Lisfranc joint [8,11]. For the present study our goal was to create the articular cartilage. maximum shear forces between all the joints that comprise the For the present study, a biomechanical cadaver model was Lisfranc complex. In plantarflexion, these joints may be com- developed to compare the fixation stability of the novel Lisfranc pressed longitudinally, with little shear forces applied. dorsal plate to that of a transarticular screw fixation. The objective The maximum ground reaction force is applied during the of this study was to quantify and compare the stability provided by stance phase of gait, on the plantar aspect of the medial phalanges the novel Lisfranc dorsal plate to the stability provided by [12]. The position of maximum ground reaction load is at transarticular screw fixation. approximately 75%–80% of the stance phase corresponding to a maximum dorsiflexion of close to 15 . With the foot positioned in 2. Methods about 15 dorsiflexion, 2 eversion, and 1 abduction [13,14], the forces acting on the foot are a vertical force equal to 1.2*Body 2.1. Specimen preparation weight (BW), a medial force equal to 0.5*BW, and an anterior force equal to 0.15*BW [13]. Fifteen matched pairs of fresh-frozen cadaveric lower legs were Therefore, in order to accurately recreate this loading scenario, obtained to conduct a paired analysis of two methods of Lisfranc we held the foot in about 15 dorsiflexion, 2 eversion, and 1 injury fixation. Each specimen was scanned using a Hologic abduction, and applied the resultant force to the plantar aspect of 2000 bone densitometer (Hologic, Inc., Waltham, MA) to deter- the medial phalanges. Furthermore, as much as possible, the load 2 mine the bone mineral density (BMD) in g/cm of the region of was applied through the big toe so as to maximize shear forces at interest (1st metatarsal, 1st cuneiform, 2nd metatarsal, and 2nd the Lisfranc joint. cuneiform). Additionally, plain radiographs were taken to docu- ment the initial conditions of all specimens. After these initial 2.2.1. Abduction loading scans, two pairs of legs were excluded from the study due to poor Based on the above estimations, during the toe-off position of bone quality (98 year old) and severe pre-existing untreated gait, the medial forefoot experiences an abduction force equaling musculoskeletal disorders (untreated talipes equinus) leaving about 5% of BW; roughly equivalent to the component of the thirteen pairs total for further testing (N = 26). ground reaction force in the medial lateral direction [13,15]. All specimens were fixed in 15 dorsiflexion, with respect to the Considering a weight of 200 lbs, typical of a moderately overweight tibia axis, to correspond with the position of the foot during 00 maximum loading during gait. To achieve this, a 3.5 screw was inserted through the calcaneus, talus, and tibia. To further stabilize Fig. 2. Abduction loading set-up: Tibia attached to MTS actuator via ring and Fig. 1. Screw placement through (1) Calcaneus, talus, and tibia, and (2) Navicular pointed screws, 1st metatarsal against metal bar on flat plate attached to load cell. and Calcaneus. N.C. Ho et al. / Foot and Ankle Surgery 25 (2019) 71–78 73 person, the medial lateral component of the ground reaction force acting on the toe is 44.5 N. Therefore, cyclic loading was applied to a peak load equal to a 44.5 N abduction load acting on the 1st metatarsal simulating the toe-off position (Fig. 2). A flat plate was attached to the top of a load cell aligned with the actuator of the biaxial MTS 858 MiniBionix servohydraulic load frame (MTS, Eden-Prairie, MN). The proximal tibia was rigidly attached to the actuator using a custom made cylindrical ring with several pointed-tip screws inserted transversely into the bone for 00 additional fixation. Holes at 1 increments were created along the length of the plate that allowed varied placement of a metal bar.
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