JBJS -- Letters to the Editor for Panchbhavi et al., 91 (5) 1143-1148

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Letters to the Editor to:

Scientific Articles:
Vinod K. Panchbhavi, Santaram Vallurupalli, Jinping Yang, and Clark R. Andersen
Screw Fixation Compared with Suture-Button Fixation of Isolated Lisfranc Ligament Injuries
J Bone Joint Surg Am 2009; 91: 1143-1148 [Abstract] [Full text] [PDF]

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Electronic letters published:

Dr. Panchbhavi and Mr. Andersen respond to Dr. Rogers and Mr. Emeagi: Vinod K. Panchbhavi, MD, FRCS, Clark Andersen, BS (2 June 2009)

Suture-Button Fixation of Isolated Lisfranc Injuries: Benedict A. Rogers, C. Emeagi (2 June 2009)

Dr. Panchbhavi and Mr. Andersen respond to Dr. Rogers and Mr. Emeagi 2 June 2009

Vinod K. Panchbhavi, MD, FRCS,
Associate Professor, Orthopedic Surgery
University of Texas Medical Branch, Galveston, Texas,
Clark Andersen, BS
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Re: Dr. Panchbhavi and Mr. Andersen respond to Dr. Rogers and Mr. Emeagi

vkpanchb{at}utmb.edu Vinod K. Panchbhavi, MD, FRCS, et al.

We thank Dr. Rogers and Mr.Emeagi for their interest in our work. The following are our responses to the points raised:
1. We agree that PMMA in the tibia can alter the tibia�s mechanical properties. However, this is not pertinent to our study, whose area of interest, the Lisfranc joint, lies far from the tibia. Testing the effects of loading was standardized in all specimens, and the MTS machine and the PMMA in the tibia were merely means to replicate body weight.
2. Current practice when treating a Lisfranc ligament injury is to immobilize the foot for three months in a non-weight-bearing cast after screw fixation of the Lisfranc joint. It is hoped that the Lisfranc ligament heals by three months, after which the screw is taken out, and only then walking, weight bearing, and cyclic loading are allowed. As noted in our article, after the three-month period, if the Lisfranc ligament does not reconstitute itself it is hoped that the suture-button may help support the Lisfranc joint. The objective in our study was strictly defined to first compare the strength of fixation achieved by a screw (the current standard of practice) to that of a suture-button. Testing cyclic loading and the endurance limit is our objective for future studies.
3. Technical feasibility limits the use of the suture-button to repairing the diastasis due to ligamentous disruption between the medial cuneiform and the base of the second metatarsal bones. For example, a suture-button cannot be used to stabilize associated fractures such as those in the bases of the metatarsals or disruption of the first metatarso-cuneiform joint.
4. We feel that further cadaver and clinical studies are necessary to evaluate the use of the suture-button technique in Lisfranc injuries. We would like to take this opportunity to reemphasize that we do not advocate any clinical use or extrapolation based on this study. The implication of this study is that the suture-button technique in the future may prove to be an acceptable alternative to a screw in stabilizing Lisfranc injury.
5. We agree that the age group of the specimens is not representative, as these injuries usually occur in younger patients. However, younger-age specimens are harder to obtain and were not necessary for this study as the right and left sides of the same cadaver served to standardize the methods used.

Suture-Button Fixation of Isolated Lisfranc Injuries 2 June 2009

Benedict A. Rogers,
Specialist Registrar
South West Thams, London, England,
C. Emeagi
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Re: Suture-Button Fixation of Isolated Lisfranc Injuries

benedictrogers{at}hotmail.com Benedict A. Rogers, et al.

To the Editor:
We read with interest the article by Panchbhavi et al. (1) and would like to make the following points:
1. The tibial intramedullary canal was filled with polymethylmethacrylate (PMMA) prior to the loading protocol. It is known from spinal studies that PMMA significantly alters the biomechanical properties of bone (2). Do the authors know how their tibial model compares with the normal physiological stresses?
2. Cyclical loading has been shown to more accurately recreate the loads that are transmitted through the foot (3). Have the authors any indication as to the response of the suture button technique, such as the endurance limit, when exposed to repetitive stresses of Lisfranc joint?
3. Myerson described that different types of Lisfranc injury (4) result from different force vectors and require different surgical techniques (5).Did this study take into account the different types of Lisfranc injuries and is the suture button technique suitable for all types of injury?
4. The implication of this study to clinical practice is unclear. Numerous techniques have been documented regarding the stabilization of these injuries (6,7) not all of which have been considered in this study.
5. The mean age of tibial/foot specimens used was 80 years, suggesting that the specimens had reduced intrinsic ligament strength. Extrapolating this cadaveric study to the treatment of these injuries, that are commonly seen in a younger population, must be done with caution.
The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
References
1. Panchbhavi VK, Vallurupalli S, Yang J, Andersen CR. Screw fixation compared with suture-button fixation of isolated Lisfranc ligament injuries. J Bone Joint Surg Am. 2009;91:1143-8.
2. Gilbert JL, Ney DS, Lautenschlager EP. Self-reinforced composite poly(methyl methacrylate): static and fatigue properties. Biomaterials. 1995;16:1043-55.
3. Daniels TR, Lau JT, Hearn TC. The effects of foot position and load on tibial nerve tension. Foot Ankle Int. 1998;19:73-8.
4. Myerson M. The diagnosis and treatment of injuries to the Lisfranc joint complex. Orthop Clin North Am. 1989;20:655-64.
5. Rajapakse B, Edwards A, Hong T. A single surgeon's experience of treatment of Lisfranc joint injuries. Injury. 2006;37:914-21.
6. Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ. Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int. 2005;26:462-73.
7. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 1986;6:225-42.