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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

Thank You

Zeeshan S. Husain, DPM, FACFAS, FASPSzee@alum.mit.edu

Annual Surgical Conference 2018