PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Jacques Lisfranc
Lisfranc Injuries and
Surgical Treatment
Bruce Cohen MD
OrthoCarolina Foot and Ankle Institute
Charlotte NC
• French surgeon in
Napoleon’s army
• Described a
midfoot amputation
for gangrene
Nouvelle methode operatoire pour l’amputation partielle du pied par son
Articulation tarso-metatarsienne: 1815
Lisfranc Definition
• Any bony or
ligamentous injury
that involves the
TMT joints
• Multiple variants
Anatomy
Anatomy
• Very rigid:
bony
architecture
Mechanisms for Injury
Direct
• Very rigid:
ligaments
–Lisfranc
ligament
most
important
stabilizer
Lisfranc Injuries and Surgical Treatment
• Plantar force
• Atypical fracture patterns
• Primarily bony component
1
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Mechanism for Injury
Mechanism for Injury
Indirect
Indirect
• Common
sports injury
• More
common
– Axial load to
the back of
the heel with
foot fixed to
the ground
– Athletes
• Axial load
• Often purely
ligamentous
Wide Variety of Patterns
Possible!
Diagnosis
Exam
• Indirect types
may be subtle
• Painful WB
• Swelling and
point tenderness
Radiographs
Diagnosis
•
•
•
•
•
• Neurovascular compromise
• Compartment syndrome
Lisfranc Injuries and Surgical Treatment
Mandatory part of the work-up
AP/lateral/oblique of foot
Weightbearing is critical!
Consider contralateral films
20% of these injuries are missed on
initial evaluation
2
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
AP View
•
•
•
•
1st TMT joint
2nd TMT joint
1-2 interspace
Naviculocuneiform
Oblique View
• 2nd TMT Joint
• 3th TMT Joint
• 4th TMT Joint
Radiographs
Lateral View
“fleck” sign
• 1st/2nd TMT Joints
Radiographs
• Subtle signs
– MT neck fracture
– MP dislocation
– “Fleck sign”
– Compression
fracture of cuboid
Lisfranc Injuries and Surgical Treatment
• Standing AP is good stress test!
• Consider contralateral xray
Radiographs
• Subtle signs
– MT neck fracture
– MP dislocation
– “Fleck sign”
– Compression
fracture of cuboid
3
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Radiographs
Radiographs
• Standing AP is good stress test!
• Subtle signs
– Beware of the
proximal
variant!
– Increasing
incidence in NFL
• Hammit/Anderso
n, TFAS ‘05
Non-weightbearing
Weightbearing
Proximal variant
• Results in an
unstable first ray
 difficulty with
push-off
Stress Testing
Formal stress testing
• Requires anesthesia,
flouroscopy
• Maneuver
– Adduction-pronation
Diagnostic Evaluation
Stress Testing
CT
• Unusual fx
patterns
• May help
guide
treatment
• Confirm
nondisplaced
(nonop)
Lisfranc Injuries and Surgical Treatment
4
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Diagnostic Evaluation
MRI
• Helpful if a
vague
presentation;
“sprain”
• May assist in
treatment and
prognosis
Nonoperative Treatment
• Stable injury pattern (non-displaced)
• 6-8 weeks protected weightbearing
– Short-leg cast
– Walker boot
• Repeat radiographs
• Expect 3-4 month recovery
Surgical Timing
• If excessive swelling,
consider delaying
surgery 10-14 days
• All severe
dislocations should be
reduced urgently
• Compartment
syndrome – operate
acutely
Lisfranc Injuries and Surgical Treatment
Treatment Goal
• Obtain/maintain
precise anatomic
reduction
• Preserve a stable,
plantigrade foot
Surgical Indications
• All unstable injury patterns
–Tarsometatarsal joints
–Intercuneiform joints
• Open fracture
• Compartment syndrome
• NV compromise
Recommendations for Fixation
• Treat individually
– Pain?
– Can not push-off?
– Progressive
diastasis?
– Unstable pattern
confirmed by
stress?
Weight-bearing
5
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Surgical Technique
•
•
Open reduction
Medial column (TMT 1-3)
– Screw fixation including
“homerun” screw
– Option: bridge plate for
TMT joints
• Lateral column (TMT 4-5)
– Pin fixation
• Lateral crush (i.e. cuboid)
– Consider ex-fix
Surgical Technique - Fixation
Since injury primarily
ligamentous…
• Takes months to heal
• Use “rigid” internal
fixation
– Screws = gold standard
• Avoid cannulated screws
– risk for breakage
Surgical Technique
Surgical Technique
• Open reduction
– Removes debris
• Leave soft
tissue/ligaments
– Can assess cartilage
– Intercuneiform of other
subtle areas of
instability?
– Confirms anatomic
reduction
Surgical Technique
• Bridge plates becoming
popular as an option to
screws - avoids articular
cartilage damage with no
loss of rigidity
– Ligamentous Lisfranc Joint
Injuries: A Biomechanical
Comparison of Dorsal Plate and
Transarticular Screw Fixation
– Frank G. Alberta, M.D; Michael S.
Aronow, M.D; Mauricio Barrero,
M.S; Vilmaris Diaz-Doran, B.S;
Raymond J. Sullivan, M.D; Douglas
J. Adams, Ph.D Farmington, CT
» Foot & Ankle International,
Vol. 26, No. 6, June 2005
Surgical Technique
• Bridge plates
Comminuted fracture
• Consider “bridge”
plate
Lisfranc Injuries and Surgical Treatment
– Can use on 1st and
2nd TMT joints
– Locking screws
beneficial
6
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Case Example
Case Example
40 yo involved in Motorcycle crash
Case Example
Surgical Technique
Lisfranc surgical
system
• Reduction devices
• Solid screws
– Cannulated assisted
50 yo involved in Fall
Surgical Technique
Postoperative
• SLC, NWB x 4-6 wks
• Boot, NWB X 4-6 wks
• Pin removal (if used)
at 6 wks
• Screw/plate removal
4-6 months
– Ligament injuries
require longer period
of protection
Lisfranc Injuries and Surgical Treatment
7
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Screw/Plate Removal
• Controversial
• Remove all lateral
column (TMT 4-5)
fixation
• Prefer to remove
transarticular TMT
1-3 hardware
1° Arthrodesis
• Indications?
– Late presentation
(8-12 wks)
– Severe articular
damage
– Risk for malunion
and nonunion
– High energy??
1° Arthrodesis
•
Treatment of primarily ligamentous
Lisfranc joint injuries: primary
arthrodesis compared with open
reduction and internal fixation.
Surgical technique.
Coetzee JC, Ly TV
JBJS 2007
–
–
–
–
Prospective RCT
41 pts
Ligamentous injury
Better short term outcome with
primary fusion
1° Arthrodesis
•
Open reduction internal fixation versus
primary arthrodesis for lisfranc
injuries: a prospective randomized
study.
Henning JA, Jones CB, Sietsma DL,
Bohay DR, Anderson JG
Foot and Ankle Int 2009
– 32 pts
– Randomized
– Lower subsequent procedures with
arthrodesis
– Biased study
– Still reasonable to do arthrodesis
Prognosis
• Expect long rehab (> 1 year)
– Midfoot pain/stiffness for average 1.3 years
postop (Brunet)
• Ultimate outcome related to adequacy of
reduction and severity of initial injury
Lisfranc Injuries and Surgical Treatment
Additional Cases
8
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Case GS
• 24 y/o basketball player with
twisting injury to foot while
rebounding
• Midfoot pain/swelling
• Unable to run
Case GS
Case GS
• Xrays
reportedly
normal
• Crutches/NWB
x 3 weeks, but
persistent pain
• Consult:
standing Xrays
obtained
Case GS
• Tender midfoot
• No instability
• What test would you order?
–CT Scan
–Bone Scan
–MRI
Case GS
Lisfranc Injuries and Surgical Treatment
Case GS
9
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Case GS
• Lisfranc sprain – no instability
• How should we treat him?
• What if he’s not better after 3
months?
• 6 months? One year?
Case DC
• Tender midfoot but minimal
swelling
• Pain with medial-lateral
compression of foot
Case DC
Case DC
• 25 y/o professional quarterback
• Twisting injury while avoiding a
sack
• Took himself out after one play
with painful weightbearing
Case DC
• Standing Xrays
– Concerned?
Take Home Points
• These are easily missed
• Standing Xrays
– Look at n-c joint
– Get comparison
views with
other side
– Have a high index of suspicion
• Need weight bearing films
– If they can’t, they need repeat exam in a week
• If concerned get follow-up sooner than
later
• Advanced imaging is helpful
– CT with fractures
– MRI with ligament/sprains
Lisfranc Injuries and Surgical Treatment
10
PAOS 2012 CME Conference ~ Hilton Head Island, SC ~ October 22 - 26, 2012
Thank You
Lisfranc Injuries and Surgical Treatment
11