LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual Surgical Conference 2018
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