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LisFranc Fractures
Zeeshan S. Husain, DPM, FACFAS, FASPSGreat Lakes Foot and Ankle Institute
September 21, 2018
Annual Surgical Conference 2018
Disclosures
• None
History
• Jacques LisFranc– 1790 – 1847
LisFranc Injury
Fleck Sign
Clinical Presentation
• Signs and symptoms– Ecchymosis– Edema– Midfoot pain– Compartment
syndrome?
• High degree of clinical suspicion– Assume LisFranc injury
until proven otherwise
Architecture
1. Peicha, et al, J Bone Joint Surg 84B:7, 2002.
2. Myerson, J Bone Joint Surg 81B:5, 1999.
Andy Goldsworthy 2001/2005, Meijer Gardens, Grand Rapids, MI
• Roman arch– Longitudinal– Transverse
• Keystone– Recessed 2nd metatarsal1
– Vassal’s principle2
Dorsal ligamentsPlantar ligaments
Soft Tissue
• Interossei ligaments– Strongest– No 1st-2nd metatarsal
ligament
• Plantar ligaments
• Dorsal ligaments– Weakest
• Secondary stabilizers– Plantar fascia– Peroneus longus tendon– Intrinsic muscles
Midtarsal Joint Motion
1st tarsometatarsal
2nd tarsometatarsal
3rd tarsometatarsal
4th metatarsal-cuboid
5th metatarsal-cuboid
Sagittal Frontal
3.5° 1.5°
0.6° 1.2°
1.6° 2.6°
9.6° 11.1°
10.2° 9.0°
Ouzounian and Shereff, Foot Ankle 10:3, 1989.
• Demographics– 0.2% of fractures1
– 1:55,000 per year1
– ♂ 2-4x :♀– Third decade most
common2,3
– ED misdiagnosis4
• 20%
Epidemiology
• Myerson5
– 76 reviewed cases• Polytrauma 81% • MVA 60%• Rest from falls and crush
injuries
1. Aitken and Poulson, J Bone Joint Surg 45A, 1963.
2. Hardcastle, et al., J Bone Joint Surg 64B:3, 1982.
3. Desmond and Chou, Foot Ankle Int 27:8, 2006.
4. Rosenberg and Patterson, Am J Orthop, Suppl, 1995.
5. Myerson, et al., Foot Ankle 6:5, 1986.
• Direct injury
• Indirect injury
Mechanism of Action
Tintinalli, et al., Tintinalli’s Emergency Medicine: A
Comprehensive Study Guide, 7th edition, 2010.
43%
57%
Classification
• Quenu and Kuss (1909)1
– Homolateral– Isolated– Divergent
• Nunley & Vertullo (2002)2
• <2mm diastasis• 2-5mm diastasis, no collapse• 2-5mm diastasis and collapse
1. Quenu and Kuss, Rev Chir 39, 1909.
2. Nunley and Vertullo, Am J Sports Med 30:6, 2002.
• Hardcastle1
– Myerson modification2
1. Hardcastle, et. al, J Bone Joint Surg 64B:3, 1982.
2. Myerson, et. al, Foot Ankle 6:5, 1986.
Classification
• Radiographs (3 views)– Metatarsal alignments
UninjuredInjured
Injured side Uninjured side
Imaging
• Radiographs (3 views)– Metatarsal re-alignment
Post-op 1mo Post-op 3mo
Imaging
• Radiographs (3 views)– Dorsal displacement
Uninjured Injured
Imaging
StressedRelaxed
NWB WB
• Plain radiographs– Diastasis
• Intermetatarsal• Intercuneiform
– “Fleck sign”– Contralateral
comparison– Stress views
• Weightbearing
Imaging
• Advanced imaging– Magnetic resonance imaging
• Look at T2 for inflammation– Bone marrow edema
• Ligamentous integrity• Alignment• For chronic midfoot pathology
Imaging
Coronal or Axial
SagittalFrontal
1. Lu, et al., Foot Ankle Inter 18:6, 1997.
• Advanced imaging– Computer tomography
• Best visualization• Surgical planning1
• For acute presentation
Imaging
Indications for Surgery
• Non-displaced– May underestimate soft
tissue injury– Prolonged NWB– Ligament integrity?– Percutaneous approach?1
• Displaced– Closed reduction
• If impending NV compromise
– ORIF or primary arthrodesis– Anatomic realignment2
1. Bleazey et al., Foot Ankle Spec 6:3, 2013.
2. Kuo, et al., J Bone Joint Surg 82A:11, 2000.
Incision Placement
• Direct visualization– Incision placement
• Between EHB and EHL• Along 4th metatarsal• Medial utility incision
– Avoid structures• Deep peroneal nerve• Deep plantar artery
– Remove soft tissue– Assess joint injury
• ORIF• Primary arthrodesis
– Anatomic reduction
Forms of Fixation
• Constructs– K-wire– Screw and K-wire– Screw
Lee, et al., Foot Ankle Inter 25:5, 2004.
• Bridge plate1
• Endobutton2
1. Alberta, et al., Foot Ankle Int 26:6, 2005.
2. Cottom, et al., J Foot Ankle Surg 47:3, 2008.
3. Lau, et al., J Foot Ankle Surg 55:4, 2016.
• Comparison3
– n = 62– Groups
• Transarticular screw• Dorsal plate• Combination• Conservative
• Conclusions– No difference– Anatomic reduction
Forms of Fixation
• Factors effecting TMT fusion rates– n = 88– Non-union rate 11.4%– Fixation
• All screws through plate onlyp = 0.004
– Graftp = 0.006
– Smokingp = 0.002
– Non-anatomic reductionp = 0.005
Fusion Rate Factors
Buda, et al., Foot Ankle Int 2018 [Epub ahead of print].
Fixation Pearls
• Proximal to distal– Intercuneiform– 2nd metatarsal– 1st ray– 3rd ray– Lateral column
• Pocket hole
Manoli and Hansen, Foot Ankle 11:2, 1990.
• 36yr old female in MVA
– Past medical history• Noncontributory
– Physical examination• Midfoot pain
– Labs• Blood alcohol 0.12%
Foot appearance
Case Scenario #1
Case Scenario #1
• Imaging– Plain films– Computer tomography
Radiographs of footCT of foot
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
Case Scenario #1
• Sequential reduction (proximal to distal)
– Incision placement• Exposure
– Intercuneiform
– Medial column• Fusion versus stabilization
– Keystone• Homerun screw
– Lateral column• K-wire
• 81yr old female– Injured left foot bending down to pickup ice– Has some pain– Usually has numbness in feet– Diabetes controlled with insulin
• Past medical history– DM nephropathy (dialysis M/W/F)– Coronary artery disease– Hip fracture (septic x3)– Morbid obesity
• BMI 54
Case Scenario #2
• Imaging– Plain films– Computer tomography
• Physical examination– Mild edema in midfoot– Midfoot pain– Pedal pulses normal– Diminished sensation
• Labs– HbA1c 6.9%– Glucose 125– GFR elevated– Creatinine elevated– BUN elevated
Case Scenario #2
Align plate
Plate anchoredScrew placement
Anchor plate distallyClamp plate
Keep screw loose
Case Scenario #2
Align plate
“Home Run” guidewireReduce jointIntercuneiform screw
Intercuneiform screwIntercuneiform screw
Case Scenario #2
Guidewire advanced
Intermetatarsal screwIM guidewire
Reduce metatarsals“Homerun” screw
Case Scenario #2
Lag screws done
Final constructFinal constructPlate fixated
Plate reducedReduce plate
Case Scenario #2
Case Scenario #2
• Final films
• 46yr old female sustained low-energy midfoot injury 3mo ago– Underwent surgical repair by
another surgeon with percutaneous fixation of LisFranc fracture
– Started walking a month ago with persistent pain
– Denies any constitutional signs of infection
Foot appearance
Case Scenario #3
• Original injury
Pre-op x-rays
Case Scenario #3
• Post-op films
Post-op x-rays
Case Scenario #3
Post-op
• Current films
Pre-op
Case Scenario #3
• Remove hardware
Case Scenario #3
• Joint exposure
Case Scenario #3
• Harvesting autograft
Case Scenario #3
• Pack and close donor site
Case Scenario #3
• Intercuneiform joint
Case Scenario #3
• Intermetatarsal joint
Case Scenario #3
• Fusion site preparation
Case Scenario #3
• Final construct
Case Scenario #3
• Final outcome
Case Scenario #3
Dowel Fusion
• Joint preparation (in situ)– “Spot welding”
Johnson and Johnson, Foot Ankle 6:5, 1986.
Ryan, et al., J Foot Ankle Surg 51:2, 2011.
Case Scenario #4
• 30yr old twisted right foot when wrestling– Past medical history
• Closed head injury
– Physical examination• Midfoot pain• Midfoot ecchymosis
– Radiographs• Normal
• 30yr old twisted right foot when wrestling– Past medical history
• Closed head injury
– Physical examination• Midfoot pain• Midfoot ecchymosis
– Computer tomography
Case Scenario #4
Incision placement Joint identification Trephine 2nd TMTJ
Bone harvesting Plate placement Plate temporarily
fixated
Case Scenario #4
Plate fixation Plate fixation Trephine 3rd TMTJ
Plate placement Plate fixation Plate fixation
Case Scenario #4
Pin lateral column Pin lateral column
Case Scenario #4
Final post-op films
Case Scenario #4
Surgical Goal
• Anatomic reduction
• If not anatomic– Poor outcome– Rapid progression to
arthrosis– Requires revision surgery– Lawsuit
Ly and Coetzee, J Bone Joint Surg 88A:3, 2006.
• Outcome comparisons– Primary arthrodesis (n = 21)
• AOFAS midfoot score 88.0– p < 0.005
• Level of activity 92%– p < 0.005
– ORIF (n =20)• AOFAS midfoot score 68.6• Level of activity 65%• Revised to arthrodesis 5
To Fuse or Not to Fuse?
To Fuse or Not to Fuse?
• ORIF / No arthrodesisStudy n OutcomeMulier1 16 68%Ly and Coetzee2 20 55%Henning3 14 90%Stavlas4 257 75/100
• Primary arthrodesisMulier1* 12 50%Ly and Coetzee2 21 100%Henning3 18 92%Sangeorzan5 16 69%
1. Mulier, et al., Foot Ankle Int 23:10, 2002.
2. Ly and Coetzee, J Bone Joint Surg 88:3, 2006.
3. Henning, et al., Foot Ankle Int 30:10, 2009.
4. Stavlas, et al., Int Orthop 34:8, 2010.
5. Sangeorzan, et al., Foot Ankle 10:4, 1990.
*- Includes partial arthrodesis
• Primary arthrodesis– High incidence of post-
traumatic arthritis
– Improved results with arthrodesis1-3
• Rationale– Medial column
• Non-essential joint
– One surgery and one recovery
– Arthrodesis as second procedure complicated by sclerosis
1. Granberry and Lipscomb, Surg Gyn Obs 114, 1962.
2. Sangeorzan, et al., Foot Ankle 10:4, 1990.
3. Komenda, et al., J Bone Joint Surg 78:11, 1966.
To Fuse or Not to Fuse?
Complications
• Risks and complications– Wound complications
– Neuritis / CRPS
– Painful hardware• When to remove?
– Non-union
– Mal-union
– Stiffness
– Post-traumatic arthritis
Post-Operative Course
• Post-operative management
– NWB cast / removable boot x8-10wks
– Kwires removed at 4-6wks
– Gradual PWB at 10wks
– Target 12-14wks in regular shoes
• With orthotics
– Physical therapy?
• ORIF– Low energy injury– Athlete– Young and healthy
• Primary arthrodesis– High energy injury– Patient issues
• IVDA• Workman’s compensation• Obesity• Elderly• Diabetic• Neuropathic• Intra-articular comminution
Personal Preferences
Conclusions
• Complex injury with high morbidity
• Goals of surgery– Sequential reduction– Anatomic reduction
• ORIF vs primary arthrodesis