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LISFRANC INJURIESFIX OR FUSE?

John Ketz,M.D.

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Introduction

• Uncommon Injuries

• Highly Variable Injuries• Trauma• Sports

• Associated with other injuries

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Introduction

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Osseous Stabilizing Structures

• Middle cuneiform is recessed proximally

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Ligamentous Stabilizing Structures

• Intertarsal

•Lisfranc

Inter-cuneiform instability

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Significance of Lisfranc Injuries

• Soft tissue injury

• Minimal bony displacement may understate ligamentous injury

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Significance of Injury

• Diagnosis is missed or delayed in up to 20% of cases

• Litigation

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Impact of Injury

• It’s a Lisfranc until proven otherwise

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Normal x-rays

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Normal x-rays

Lateral: A metatarsal should never be more dorsal than its respective tarsal bone

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• Dynamic Joints• Weight bearing radiographs crucial

Imaging of Lisfranc Injuries

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• Contralateral views

Imaging of Lisfranc Injuries

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Closed Reduction

• Urgent if impending skin compromise

• Can be blocked by tendons, ligaments, bone

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Indications for Surgery

Ligamentous Instability Multiple fractures Displaced fractures

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Operative Treatment

OptionsORIF

Primary Arthrodesis

Percutaneous pinning/screws

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Operative Treatment

• “ I always do ORIF, and then I take out my screws

• “I always fuse the joints”

• “ I always do ORIF, but I leave my screws in”

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Rationale for ORIF

• Preserve the joints at all costs

• Do not eliminate a motion segment of the foot

• Hard to make the multiple fractures and a fusion heal

• Traditional treatment

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Hardware

• What to use?

• Screws

• 3.5mm or 4.0mm cortical

• Cannulated screws

• Spanning Plates• “joint sparing”

• comminution

• Tightrope

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Hardware• Plates

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Hardware Removal?

• Indications?• When?

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Operative Technique

Incisions

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Operative TechniqueDissection/Access

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Operative Technique• Dissection/Access

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Operative Technique• Dissection/Access

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Operative Technique

• Reduction/Temporary Fixation

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Operative Technique

• Where to start?• Medial to lateral

• Lateral to medial

• Least to most comminuted

• My Preference• Reduce any intercuneiform

instability• Key in the second ray• 1st, 3rd then 4th and 5th

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Operative Technique

• Internal Fixation

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Operative Technique

• Internal Fixation

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Operative Technique

• Internal Fixation

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Results of ORIF

Requires anatomic reduction Poor outcomes Rapid progression of arthrosis Need for further procedures

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Alternatives to ORIF?

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Primary Arthrodesis High incidence of PTOA post Lisfranc injury Recommended primary fusion

Granberry Surg Gyn Obs 1962

Significant improvement after midfoot arthrodesis for PTOA

Improved results with early fusion for PTOA midfoot Sangeorzan et al FAI 1990 Komenda et al JBJS am 1996

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Rationale for Fusion

• Medial column of the midfoot functions rigidly during gait for stablility• “non-essential joints”

• Lateral column (4th, 5th TMT) is the mobile midfoot segment

• One operation, one recovery period

• Fusion after ORIF is technically more difficult

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Primary Arthrodesis(PA) vs ORIF

Ly & Coetzee JBJS 2006

Randomized prospective study, improved results in PA vs ORIF for ligamentous injuries

Henning et al FAI 2009

Less secondary procedures and trends towards better outcomes in PA vs ORIF

Mulier et al FAI 2002

Advocated for partial primary arthrodesis for medial column

Reduce and Pin unstable joints

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Remove pins and debride one joint at a time

Screw Fixation

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Pin 4th and 5th if unstable, don’t fuse

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DO NOT fuse in situ!

Comminution

Fuse with Plates

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Post-Op

• Remove K wires at 4 weeks

• NWB Short leg cast(fusion) boot (ORIF) X 8 weeks

• Boot, gradual WB over next 2-4 weeks

• PT or HEP

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What Do I Do?

Fusion High energy injuries

Patients selection (IVDA, WC, obese, elderly)

Highly comminuted joints

ORIF Low energy Athletes, young&healthy

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Do I fuse everyone?

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Summary

• Complex Injuries with poor outcomes

• Each injury, patient unique

• Do not miss subtle injuries

• Goal of fixation Stable painless plantigradefoot

• Fuse vs. ORIF – still controversial