The Surgical Management of Midfoot ArthritisEtiology of “Lisfranc” Injuries •Fairly rare –1...
Transcript of The Surgical Management of Midfoot ArthritisEtiology of “Lisfranc” Injuries •Fairly rare –1...
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Lisfranc Injuries
Alan J. Zonno, M.D.
Rockhill Orthopaedic Specialists
Lee’s Summit, MO
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Disclosures
• None
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History
• Jacques Lisfranc de Saint-Martin – Surgeon in Napoleon's army
• 1813-1814
– Midfoot amputations • Frostbite
• Gangrene
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Midfoot Anatomy
• 11 Articulations
– 5 Tarsometatarsal
– 2 Intercuneiform & 1 Cuboid-Cuneiform
– 3 Navicular – Cuneiform
Lenczner et al (J Trauma 1974)
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Midfoot Anatomy
• “Lisfranc complex”
– All 5 MT bases & respective articulations
• Tarsometatarsal (TMT) joint complex
– Forms transverse arch of the foot
– Supported by
• Strong plantar and interosseous ligaments
• Plantar soft tissue structures – Plantar fascia & peroneus longus tendon
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Midfoot Columns
• Medial
• Middle
• Lateral
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Patel et al (JAAOS 2010)
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Unique Features
• “Roman Arch” • “Keystone” • “Lisfranc ligament”
– Plantar connection b/t 2nd MT base & medial cuneiform
– No ligament b/t 1st & 2nd MT bases • Increased risk to injury
– Patel et al (JAAOS, 2010)
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Biomechanics
• Function – Allows force transfer from hindfoot to
forefoot
• Subtalar joint everts at heel strike – Supple midfoot at heelstrike into midstance
– Shock absorption
• Subtalar joint inverts at toe off – Rigid lever arm for push-off
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Etiology of “Lisfranc” Injuries
• Fairly rare – 1 per 55,000 annually
– 0.2% of all fractures
• Most common at 20 – 30 years of age
• Males 2 – 3 x more common than females
• Myerson et al (Foot Ankle 1986): 76 Lisfranc fracture-dislocations – 66% MVA
– 33% divided b/t crush & falls from height
– 58% poly-trauma patients
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Etiology
• 33% low energy injuries
– 4% of NFL football players per year
• ~20% of injuries missed/misdiagnosed
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Mechanism of Injury
• Direct trauma
– High energy/blunt trauma to dorsal foot
– Crush injuries with extensive soft tissue edema
– Worse outcomes
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Mechanism of Injury
• Indirect trauma
– Axial loading of a plantarflexed foot
– Forced abduction or twisting of the foot
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Classification of Injuries
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Diagnosis
• Direct, high energy, crush injuries
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Diagnosis
• Indirect low-energy injuries
– Require high index of suspicion
– Pain with weight-bearing
– Tenderness over the midfoot
– Plantar ecchymosis
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Imaging Studies
• Radiographs – Weight bearing (WB) if possible
– Contralateral “normal” comparison
– Stress views
• CT scan – More sensitive in subtle injuries
• MRI – “Lisfranc ligament” disruption or
bony edema
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Treatment
• Stable injuries
– No displacement with WB x-ray or stress views
– Midfoot “sprains”
• Unstable injuries
– Displacement with WB x-ray or stress views
– Spectrum of severity involving ligament and/or bony injuries
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Treatment
• Non-operative
– Reserved for stable injuries – i.e. sprains
– Unstable injuries historically do not do well
– 17 – 30% “good to excellent” results
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Non-operative Protocol
• CAM boot for 6 – 8 weeks – WB as comfort permits
– Sedentary/seated work immediately (if available)
– RTW in boot when full WB
• Interval X-rays necessary to detect late instability
• Transition into shoes after 6 – 8 weeks – Physical therapy
– Work conditioning
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Life After the Boot…
• Activity modification
• Shoe wear modification
– Stiff soles/rocker-bottoms
– Carbon-fiber inserts
– Orthotics
• NSAIDs
• Corticosteroid injections
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• Full-length CFP – Reduce plantar pressures & medial midfoot contact
time • Rao et al (J Orthop Sports Phys Ther, 2009)
• Khosla et al (FAI, 2009)
• Full-length >> ¾ length CFP – 20% reduction in medial midfoot pressure (p=0.015)
– 8.5% reduction in medial midfoot contact time (p<0.01) • Baumhauer et al (J Orthop Sports Phys Ther, 2009)
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How about “Orthotics?”
• Ibuki et al (Prosthet Ortho Int, 2010)
– 57 pts with custom full-length semi-rigid orthotics
– 36 pts received CF plate as well
– Significantly improved pain, activity level & footwear comfort in both groups
– No difference between groups
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Surgical Management
• Unstable injuries
• 50 – 90% “good to excellent” results
• Immediate technical considerations
– ORIF
– Primary arthrodesis (PA)
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Fixation vs. Primary Arthrodesis Coetzee et al (JBJS 2007)
• Indications for PA – Purely ligamentous disruptions
– Multidirectional instability
– Comminuted intra-articular fracture at 2nd MT
– Crush injury with intra-articular fx-dislocation
• Contraindications to PA – Open physes
– Subtle injury, minimal to no displacement
– Unidirectional instability
– Unstable extra-articular fx
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Additional Contraindications to PA (in my humble opinion)
• Tobacco use
• Advanced peripheral vascular disease
• Severe vitamin D deficiency
• Potential noncomplicance
• Pre-existing deformity
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Midfoot Realignment
• Re-establish
– Talo-1st MT lines
– Column orientation
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Realignment Matters...
• Sangeorzan (Foot Ankle 1990)
– Alignment – ONLY useful factor to determine outcome after fixation of TMT joint injuries
• Myerson (JBJS 1996)
– In situ fusion indicated with SLIGHT deformity • Displacement < 2mm
• Angulation < 15 deg
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Co-existing deformities?
• Hindfoot valgus
– Medializing calcaneus osteotomy • Zonno & Myerson (Foot Ankle Clin 2011)
• Forefoot ABD
– LC length if talar head uncovered > 40% • Bluman at al (Foot Ankle Clin 2007)
• Gastrocnemius or Achilles contracture
– Gastroc recession or TAL
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• DiGiovanni et al (JBJS 2000)
– 35/42 with anatomic reduction s/p ORIF did best
– Non-anatomic reduction
• Increased % of post-traumatic DJD
– Pure ligamentous injury
• Tended to have higher rate of post-traumatic DJD
• Indication for primary arthrodesis
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Risk-Reward Profiles
• ORIF • (-) Risk of post-traumatic DJD
• (-) Need for more hardware removals
• (+) Nonunion is not a concern
• (+) Pre-existing deformity less of a concern
• Primary Arthrodesis • (+) Fewer hardware removals
• (+) Ligamentous injuries do better
• (-) Nonunion risk is real (especially smokers)
• (-) Need correct pre-existing deformities
• (+/-) for work comp patients
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Dual-Incision Approach
• Midline
– Just lateral to 2nd MT
• Medial
– Over 1st TMT joint
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Fixation – Dealer’s Choice
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Conclusions
• Lisfranc sprains treated non-operatively
• Unstable injuries require surgery
• ORIF vs. primary arthrodesis – a time and a place for everything
• Correct concomitant deformity
• Communicate with the patient