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LisFranc Fractures

Zeeshan S. Husain, DPM, FACFAS, FASPS Great 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

•

• 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

Sagittal Frontal

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 only p = 0.004

– Graft p = 0.006

– Smoking p = 0.002

– Non-anatomic reduction p = 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

“