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Lisfranc fracture dislocation
Mr MS Siddique MD FRCS MCh Orth FRCS Tr & Orth
Miss E Robinson & Dr S Lyons Newcastle upon Tyne Hospitals NHS Trust
Importance of Diagnosis
• Incidence is 1 in 55,000• Account for 0.2% of all fractures • Missed diagnosis leads to poor prognosis
Anatomy
Mortise of Lisfranc
Shallow mortise > Inj
Peicha 2002 JBJS
Total Ankle Replacement
Mechanism of Injury
Axial loading (toes dorsiflexed, ankle in equinus)
Rotational forces (medial/lateral) with forced forefoot
abduction
Presentation
• Ecchymosis• Pain, swelling & tenderness • Painful passive abduction/
pronation • Midfoot instability Wt. • Dorsalis pedis absent • Compartment syndrome
Classification
Hardcastle 1982 Myerson 1986
Type A All MT Complete Displacement
Type B Partial Incongruity
One or more MT Displacement
1 Medial
2 Lateral
Type C Divergent Pattern
1 Partial Incongruity
2 Total Incongruity
Investigation
X- Rays
Fleck sign
Investigation
X- Rays
Stress Views
CT / MRI
Management Non Surgical
• Not fit for surgery
• Stress views FWB stable
• Diastasis <2mm cuneiforms & metatarsals
• <15˚ talometatarsal angle
Literature Recommendation
No role of close reduction & POP without fixation
• Up to 60% failure rate• Poor long term result
• Level IV Evidence• Jeffreys 1963, Goossens 1983
Operative Options
Close Reduction
Percutaneous K Wiring
Transarticular Fixation
Arthrodesis
Perfect closed reduction
• Diastasis <2mm
• cuneiforms & metatarsals
• <15˚ talometatarsal angle
Our preference
• Reduce & fix the intra-articular fracture without crossing the articular surfaces
• Buttress the fracture dislocation of joint with mini-plate if unstable
Open reduction & Fixation
Dorsal plate Vs Transarticular screws
Similar Ability to reduce &
Resist displacement
1st & 2nd TMTJ
Alberta et al Foot & Ankle int 2005
Not Recommended
POP Immobilisation without reduction
ORIF with K wires of 1st , 2nd & 3rd TMTJ
ORIF with Transarticular screws TMTJ
Primary Arthrodesis of 4th & 5th TMTJ
ORIF K Wiring
Cadaveric
Model
Open reduction & Fixation
Open reduction & Fixation
Open reduction & Fixation
Arthrodesis
• Unable to achieve quality reduction or stabilise without penetrating the articular surfaces.
• Rate arthritis
• 17% anatomic reduction
• 80% non-anatomic reduction
Primary arthrodesis for ligamentous injuries
41 patients 42 months follow up
AOFAS
ORIF Arthrodesis
68.6 88
Level 1 study Ly & Coetzee JBJS 2006
Arthrodesis for ligamentous injuries
Poor healing potential of ligaments
Loss of correction
Greater deformity
Degenerative arthritis
Level 1 study Ly & Coetzee JBJS 2006
Complications
• Midfoot arthritis
• Compartment Syndrome
• Complex regional pain syndrome
Outcome
• Complete reduction : complete satisfaction NO
• Initial articular damage or inadequate reduction directly correlates with OA
Arntz et al 1988
Outcome
• Precise anatomical reduction : optimal result
• Buzzard & Briggs 1998
• Poor outcome in compensation claim cases
• Calder et al 2004
Summary
• Investigate fully if suspect
• Outcome : Precise reduction
• Plate fixation : Transarticular screws
• Arthrodesis : Unable to achieve quality reduction
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