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Page 1: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

LisFranc Fractures

Zeeshan S. Husain, DPM, FACFAS, FASPSGreat Lakes Foot and Ankle Institute

September 21, 2018

Annual Surgical Conference 2018

Page 2: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Disclosures

• None

Page 3: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

History

• Jacques LisFranc– 1790 – 1847

Page 4: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

LisFranc Injury

Fleck Sign

Page 5: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Clinical Presentation

• Signs and symptoms– Ecchymosis– Edema– Midfoot pain– Compartment

syndrome?

• High degree of clinical suspicion– Assume LisFranc injury

until proven otherwise

Page 6: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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

Page 7: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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

Page 8: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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.

Page 9: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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.

Page 10: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Direct injury

• Indirect injury

Mechanism of Action

Tintinalli, et al., Tintinalli’s Emergency Medicine: A

Comprehensive Study Guide, 7th edition, 2010.

43%

57%

Page 11: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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.

Page 12: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Hardcastle1

– Myerson modification2

1. Hardcastle, et. al, J Bone Joint Surg 64B:3, 1982.

2. Myerson, et. al, Foot Ankle 6:5, 1986.

Classification

Page 13: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Radiographs (3 views)– Metatarsal alignments

UninjuredInjured

Injured side Uninjured side

Imaging

Page 14: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Radiographs (3 views)– Metatarsal re-alignment

Post-op 1mo Post-op 3mo

Imaging

Page 15: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Radiographs (3 views)– Dorsal displacement

Uninjured Injured

Imaging

Page 16: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

StressedRelaxed

NWB WB

• Plain radiographs– Diastasis

• Intermetatarsal• Intercuneiform

– “Fleck sign”– Contralateral

comparison– Stress views

• Weightbearing

Imaging

Page 17: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Advanced imaging– Magnetic resonance imaging

• Look at T2 for inflammation– Bone marrow edema

• Ligamentous integrity• Alignment• For chronic midfoot pathology

Imaging

Page 18: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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

Page 19: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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.

Page 20: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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

Page 21: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Forms of Fixation

• Constructs– K-wire– Screw and K-wire– Screw

Lee, et al., Foot Ankle Inter 25:5, 2004.

Page 22: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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

Page 23: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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].

Page 24: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Fixation Pearls

• Proximal to distal– Intercuneiform– 2nd metatarsal– 1st ray– 3rd ray– Lateral column

• Pocket hole

Manoli and Hansen, Foot Ankle 11:2, 1990.

Page 25: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 36yr old female in MVA

– Past medical history• Noncontributory

– Physical examination• Midfoot pain

– Labs• Blood alcohol 0.12%

Foot appearance

Case Scenario #1

Page 26: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Imaging– Plain films– Computer tomography

Radiographs of footCT of foot

Page 27: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 28: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 29: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 30: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 31: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 32: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 33: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 34: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #1

• Sequential reduction (proximal to distal)

– Incision placement• Exposure

– Intercuneiform

– Medial column• Fusion versus stabilization

– Keystone• Homerun screw

– Lateral column• K-wire

Page 35: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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

Page 36: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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

Page 37: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Align plate

Plate anchoredScrew placement

Anchor plate distallyClamp plate

Keep screw loose

Case Scenario #2

Page 38: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Align plate

“Home Run” guidewireReduce jointIntercuneiform screw

Intercuneiform screwIntercuneiform screw

Case Scenario #2

Page 39: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Guidewire advanced

Intermetatarsal screwIM guidewire

Reduce metatarsals“Homerun” screw

Case Scenario #2

Page 40: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Lag screws done

Final constructFinal constructPlate fixated

Plate reducedReduce plate

Case Scenario #2

Page 41: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #2

• Final films

Page 42: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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

Page 43: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Original injury

Pre-op x-rays

Case Scenario #3

Page 44: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Post-op films

Post-op x-rays

Case Scenario #3

Page 45: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Post-op

• Current films

Pre-op

Case Scenario #3

Page 46: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Remove hardware

Case Scenario #3

Page 47: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Joint exposure

Case Scenario #3

Page 48: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Harvesting autograft

Case Scenario #3

Page 49: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Pack and close donor site

Case Scenario #3

Page 50: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Intercuneiform joint

Case Scenario #3

Page 51: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Intermetatarsal joint

Case Scenario #3

Page 52: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Fusion site preparation

Case Scenario #3

Page 53: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Final construct

Case Scenario #3

Page 54: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• Final outcome

Case Scenario #3

Page 55: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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.

Page 56: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Case Scenario #4

• 30yr old twisted right foot when wrestling– Past medical history

• Closed head injury

– Physical examination• Midfoot pain• Midfoot ecchymosis

– Radiographs• Normal

Page 57: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 30yr old twisted right foot when wrestling– Past medical history

• Closed head injury

– Physical examination• Midfoot pain• Midfoot ecchymosis

– Computer tomography

Case Scenario #4

Page 58: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Incision placement Joint identification Trephine 2nd TMTJ

Bone harvesting Plate placement Plate temporarily

fixated

Case Scenario #4

Page 59: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Plate fixation Plate fixation Trephine 3rd TMTJ

Plate placement Plate fixation Plate fixation

Case Scenario #4

Page 60: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Pin lateral column Pin lateral column

Case Scenario #4

Page 61: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Final post-op films

Case Scenario #4

Page 62: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Surgical Goal

• Anatomic reduction

• If not anatomic– Poor outcome– Rapid progression to

arthrosis– Requires revision surgery– Lawsuit

Page 63: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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?

Page 64: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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

Page 65: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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?

Page 66: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Complications

• Risks and complications– Wound complications

– Neuritis / CRPS

– Painful hardware• When to remove?

– Non-union

– Mal-union

– Stiffness

– Post-traumatic arthritis

Page 67: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

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?

Page 68: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

• 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

Page 69: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Conclusions

• Complex injury with high morbidity

• Goals of surgery– Sequential reduction– Anatomic reduction

• ORIF vs primary arthrodesis

Page 70: LisFranc Fractures - ASPS › resources › Documents... · LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018 Annual

Thank You

Zeeshan S. Husain, DPM, FACFAS, [email protected]

Annual Surgical Conference 2018


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