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LisFranc Fractures - ASPS › resources › Documents... · PDF file LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21,...

Jul 05, 2020

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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