Slide 1

LISFRANC INJURIES OF THE FOOTWilliam S. Crawford, MD

Texas Foot & Ankle Orthopaedics

25 February 2017

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DISCLOSURES

• I have no relevant financial disclosures

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OBJECTIVES

• Discuss relevant midfoot anatomy

• Identify common injury mechanisms and injury patterns of Lisfranc Injuries

• Diagnose Lisfranc Injuries to the foot

• Discuss treatment options for Lisfranc Injuries

• Discuss outcomes for different treatment options

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OSSEOUS MIDFOOT ANATOMY

• Tarsometatarsal joints/Intertarsal

joints

• 2nd TMT set posteriorly

• Frontal plane stability

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Slide 5

OSSEOUS MIDFOOT ANATOMY

• Roman Arch

• 2nd MT Base = Keystone

• Dorsal Transverse Arch

• Prevents plantar

displacement

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LIGAMENTOUS MIDFOOT ANATOMY

• A - Dorsal ligaments

• B - Interosseous ligaments

• Strongest, Lisfranc Ligament

• C - Plantar ligaments

• Second oblique ligament

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MUSCULAR MIDFOOT ANATOMY

• Interossei

• Associated MT neck fx vs MTP

dislocations

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COLUMN ANATOMY

• Medial Column

• Longitudinal Arch

• Lateral Column

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MECHANISMS OF INJURY

• Direct – force applied to

TMT

• High Energy

• Less common

• Plantar dislocation

associated with crush

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MECHANISMS OF INJURY

• Indirect – axial load or twisting

hyper-PF

• Lower energy

• More Common

• Crush/open

• Compartments

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CLINICAL EVALUATION

• Swelling at midfoot

• Point tenderness

• Plantar ecchymosis

• Foot deformity

• Suspicion Radiographs

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NORMAL RADIOGRAPHS

• AP film

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NORMAL RADIOGRAPHS

• Internal Oblique

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NORMAL RADIOGRAPHS

• Lateral

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AP INJURY RADIOGRAPHS

• Obvious vs subtle

• WB films critical

• Contralateral

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LATERAL WB RADIOGRAPH

• Findings can be subtle

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INTERNAL OBLIQUE RADIOGRAPHS

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INTRAOPERATIVE STRESS VIEWS

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ADVANCED IMAGING

• CT scan

• Flecks

• MRI

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POSITIVE XR FINDINGS

• ANY joint

displacement =

instability

• Fracture displacement

does not mean joint

displacement

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CLASSIFICATION

• Not useful

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NON-OPERATIVE TREATMENT

• No joint displacement on WB films/CT

• Patients with comorbid conditions

precluding surgery

• For fx - NWB in boot vs cast x6-8 weeks

• Transition to stiff-soled shoe vs CF shank

• Midfoot sprain – WB in Boot vs CF shank

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SURGICAL TREATMENT

• When soft tissues allow

• Indicated with ANY joint

instability

• Percutaneous fixation **

• ORIF

• Primary Arthrodesis

• Plates vs Screws

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Slide 24

GOALS OF SURGICAL TREATMENT

• Anatomic reduction

• 50-95% patients good – excellent

• Versus 17-30%

• Painless, stable, plantigrade foot

• Stiff Medial Column

• Flexible Lateral Column

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ORIF VS PRIMARY ARTHRODESIS

• Hot topic

• OITE answer:

• ORIF

• Fracture/Dislocation

• Arthrodesis

• Pure ligamentous injury

• Delayed diagnosis

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ACUTE LISFRANC POST-OP PROTOCOL

• NWB 8-12 weeks

• Week 1-2 – post-op splint

• Week 3-8 – transition to CAM boot for early ROM ankle, hindfoot toes

• Week 9 (8 weeks out) – 25% WB in CAM boot

• Week 10 – 50% WB in CAM boot

• Week 11 – 75% WB in CAM boot

• Week 12 – 100% WB in CAM boot

• Week 13 (12 weeks out) wean boot to shoe, consider CF shank

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COMPLICATIONS

• Post-traumatic arthritis

• 100% have radiographic signs - not necessarily symptomatic

• Vascular compromise

• Rare

• Compartment syndrome

• High incidence in crush injuries

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OPEN TREATMENT PEARLS

• Delay definitive management until skin

allows

• Provisional fixation if significant

displacement (K-wires vs mini-exfix)

• Hinterman retractor/small lamina spreader

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WHAT I DO

• Screws for low energy

• Plates for comminution

• Primary Arthrodesis 1-3 TMT,

intercuneiform, NC

• K-wire vs exfix for 4th and 5th

TMT +/- ORIF Cuboid

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Slide 30

CASE 1 – 16 YO M FOOTBALL INJURY

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CASE 1 CONTINUED

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CASE 1 – 12 WEEKS OUT WB

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CASE 2 – 45 YO M MCC

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CASE 2 CONTINUED

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Slide 35 CASE 2 CONTINUED

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ORIF VS ARTHRODESIS

• Higher rate of subsequent surgery for HWR +/- fusion in ORIF

• If ORIF, should remove HW at 3-4 months, otherwise you’re a “closet fuser”

• No functional differences in outcomes between ORIF and Arthrodesis

• 92% vs 65% ***

*** Ly, Thuan V., and J. Chris Coetzee. "Treatment Of Primarily Ligamentous

Lisfranc Joint Injuries." The Journal of Bone and Joint Surgery-American Volume 88.3

(2006): 514-20. Print.

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Slide 37

REFERENCES

• Benirschke, Stephen K., Eric Meinberg, Sarah A. Anderson, Clifford B. Jones, and Peter A. Cole. "Fractures and Dislocations of the Midfoot: Lisfranc and Chopart Injuries." The Journal of Bone and Joint Surgery-American Volume 94.14 (2012):

1326-337. Print.

• Desmond, Elizabeth A., and Loretta B. Chou. "Current Concepts Review: Lisfranc Injuries." Foot & Ankle International 27.8 (2006): 653-60. Print.

• Dubois-Ferrière, Victor, Anne Lübbeke, Ashwin Chowdhary, Richard Stern, Dennis Dominguez, and Mathieu Assal. "Clinical Outcomes and Development of Symptomatic Osteoarthritis 2 to 24 Years After Surgical Treatment of

Tarsometatarsal Joint Complex Injuries." The Journal of Bone and Joint Surgery 98.9 (2016): 713-20. Print.

• Gallagher, Sean M., Noe A. Rodriguez, Clark R. Andersen, William M. Granberry, and Vinod K. Panchbhavi. "Anatomic Predisposition to Ligamentous Lisfranc Injury: A Matched Case-Control Study." The Journal of Bone and Joint Surgery-

American Volume 95.22 (2013): 2043-047. Print.

• Henning, Jeffrey A., Clifford B. Jones, Debra L. Sietsema, Donald R. Bohay, and John G. Anderson. "Open Reduction Internal Fixation versus Primary Arthrodesis for Lisfranc Injuries: A Prospective Randomized Study." Foot & Ankle

International 30.10 (2009): 913-22. Print.

• Kaar, Scott. "Lisfranc Joint Displacement Following Sequential Ligament Sectioning." The Journal of Bone and Joint Surgery (American) 89.10 (2007): 2225. Print.

• Komenda, Gregory A., Mark S. Myerson, and Kent R. Biddinger. "Results of Arthrodesis of the Tarsometatarsal Joints after Traumatic Injury*â€." The Journal of Bone & Joint Surgery 78.11 (1996): 1665-76. Print.

• Lee, Cassandra A., John P. Birkedal, Emilee A. Dickerson, Paul A. Vieta, Lawrence X. Webb, and Robert D. Teasdall. "Stabilization of Lisfranc Joint Injuries: A Biomechanical Study." Foot & Ankle International 25.5 (2004): 365-70. Print.

• Lewis, Charlie, Cyril Mauffrey, and Edward Dickenson. "Open Reduction and Internal Fixation Compared with Primary Arthrodesis of Lisfranc Injuries." Current Orthopaedic Practice 23.6 (2012): 595-600. Print.

• Ly, Thuan V., and J. Chris Coetzee. "Treatment Of Primarily Ligamentous Lisfranc Joint Injuries." The Journal of Bone and Joint Surgery-American Volume 88.3 (2006): 514-20. Print.

• Myerson, M. S. "The Diagnosis and Treatment of Injury to the Tarsometatarsal Joint Complex." The Journal of Bone and Joint Surgery 81.5 (1999): 756-63. Print.

• Reinhardt, Keith R., Luke S. Oh, Patrick Schottel, Matthew M. Roberts, and David Levine. "Treatment of Lisfranc Fracture-Dislocations with Primary Partial Arthrodesis." Foot & Ankle International 33.1 (2012): 50-56. Print.

• Smith, Nicholas, Craig Stone, and Andrew Furey. "Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis." Clinical Orthopaedics and

Related Research® 474.6 (2015): 1445-452. Print.

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