Annual Surgical Conference LisFranc Fractures. Zeeshan S. Husain, DPM, FACFAS, FASPS. Great Lakes Foot and Ankle Institute September 21, 2018
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1 Annual Surgical Conference 2018 LisFranc Fractures Zeeshan S. Husain, DPM, FACFAS, FASPS Great Lakes Foot and Ankle Institute September 21, 2018
2 None Disclosures
3 Jacques LisFranc History
4 LisFranc Injury Fleck Sign
5 Clinical Presentation Signs and symptoms Ecchymosis Edema Midfoot pain Compartment syndrome? High degree of clinical suspicion Assume LisFranc injury until proven otherwise
6 Architecture Roman arch Longitudinal Transverse Keystone Recessed 2 nd metatarsal 1 Vassal s principle 2 Andy Goldsworthy 2001/2005, Meijer Gardens, Grand Rapids, MI 1. Peicha, et al, J Bone Joint Surg 84B:7, Myerson, J Bone Joint Surg 81B:5, 1999.
7 Soft Tissue Interossei ligaments Strongest No 1 st -2 nd metatarsal ligament Plantar ligaments Dorsal ligaments Weakest Secondary stabilizers Plantar fascia Peroneus longus tendon Intrinsic muscles Plantar ligaments Dorsal ligaments
8 Midtarsal Joint Motion 1 st tarsometatarsal 2 nd tarsometatarsal 3 rd tarsometatarsal 4 th metatarsal-cuboid 5 th metatarsal-cuboid Sagittal Frontal Ouzounian and Shereff, Foot Ankle 10:3, 1989.
9 Epidemiology Demographics 0.2% of fractures 1 1:55,000 per year 1 2-4x : Third decade most common 2,3 ED misdiagnosis 4 20% Myerson 5 76 reviewed cases Polytrauma 81% MVA 60% Rest from falls and crush injuries 1. Aitken and Poulson, J Bone Joint Surg 45A, Hardcastle, et al., J Bone Joint Surg 64B:3, Desmond and Chou, Foot Ankle Int 27:8, Rosenberg and Patterson, Am J Orthop, Suppl, Myerson, et al., Foot Ankle 6:5, 1986.
10 Mechanism of Action Direct injury 57% 43% Indirect injury Tintinalli, et al., Tintinalli s Emergency Medicine: A Comprehensive Study Guide, 7 th edition, 2010.
11 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, Nunley and Vertullo, Am J Sports Med 30:6, 2002.
12 Classification Hardcastle 1 Myerson modification 2 1. Hardcastle, et. al, J Bone Joint Surg 64B:3, Myerson, et. al, Foot Ankle 6:5, 1986.
13 Imaging Radiographs (3 views) Metatarsal alignments Injured Uninjured Injured side Uninjured side
14 Imaging Radiographs (3 views) Metatarsal re-alignment Post-op 1mo Post-op 3mo
15 Imaging Radiographs (3 views) Dorsal displacement Uninjured Injured
16 Imaging NWB WB Plain radiographs Diastasis Intermetatarsal Intercuneiform Fleck sign Contralateral comparison Stress views Weightbearing Relaxed Stressed
17 Imaging Advanced imaging Magnetic resonance imaging Look at T2 for inflammation Bone marrow edema Ligamentous integrity Alignment For chronic midfoot pathology
18 Imaging Advanced imaging Computer tomography Best visualization Surgical planning 1 For acute presentation Coronal or Axial Sagittal Frontal 1. Lu, et al., Foot Ankle Inter 18:6, 1997.
19 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 realignment 2 1. Bleazey et al., Foot Ankle Spec 6:3, Kuo, et al., J Bone Joint Surg 82A:11, 2000.
20 Direct visualization Incision placement Between EHB and EHL Along 4 th metatarsal Medial utility incision Avoid structures Deep peroneal nerve Deep plantar artery Remove soft tissue Assess joint injury ORIF Primary arthrodesis Anatomic reduction Incision Placement
21 Forms of Fixation Constructs K-wire Screw and K-wire Screw Lee, et al., Foot Ankle Inter 25:5, 2004.
22 Forms of Fixation Bridge plate 1 Endobutton 2 Comparison 3 n = 62 Groups Transarticular screw Dorsal plate Combination Conservative Conclusions No difference Anatomic reduction 1. Alberta, et al., Foot Ankle Int 26:6, Cottom, et al., J Foot Ankle Surg 47:3, Lau, et al., J Foot Ankle Surg 55:4, 2016.
23 Fusion Rate Factors Factors effecting TMT fusion rates n = 88 Non-union rate 11.4% Fixation All screws through plate only p = Graft p = Smoking p = Non-anatomic reduction p = Buda, et al., Foot Ankle Int 2018 [Epub ahead of print].
24 Fixation Pearls Proximal to distal Intercuneiform 2 nd metatarsal 1 st ray 3 rd ray Lateral column Pocket hole Manoli and Hansen, Foot Ankle 11:2, 1990.
25 Case Scenario #1 36yr old female in MVA Past medical history Noncontributory Physical examination Midfoot pain Labs Blood alcohol 0.12% Foot appearance
26 Case Scenario #1 Imaging Plain films Computer tomography CT of foot Radiographs of foot
27 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
28 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
29 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
30 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
31 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
32 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
33 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
34 Case Scenario #1 Sequential reduction (proximal to distal) Incision placement Exposure Intercuneiform Medial column Fusion versus stabilization Keystone Homerun screw Lateral column K-wire
35 Case Scenario #2 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
36 Case Scenario #2 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 Imaging Plain films Computer tomography
37 Case Scenario #2 Align plate Clamp plate Anchor plate distally Keep screw loose Screw placement Plate anchored
38 Case Scenario #2 Align plate Intercuneiform screw Intercuneiform screw Intercuneiform screw Reduce joint Home Run guidewire
39 Case Scenario #2 Guidewire advanced Homerun screw Reduce metatarsals IM guidewire Intermetatarsal screw
40 Case Scenario #2 Lag screws done Reduce plate Plate reduced Plate fixated Final construct Final construct
41 Final films Case Scenario #2
42 Case Scenario #3 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
43 Case Scenario #3 Original injury Pre-op x-rays
44 Case Scenario #3 Post-op films Post-op x-rays
45 Case Scenario #3 Current films Pre-op Post-op
46 Remove hardware Case Scenario #3
47 Joint exposure Case Scenario #3
48 Harvesting autograft Case Scenario #3
49 Pack and close donor site Case Scenario #3
50 Intercuneiform joint Case Scenario #3
51 Intermetatarsal joint Case Scenario #3
52 Fusion site preparation Case Scenario #3
53 Final construct Case Scenario #3
54 Final outcome Case Scenario #3
55 Dowel Fusion Joint preparation (in situ) Spot welding Johnson and Johnson, Foot Ankle 6:5, Ryan, et al., J Foot Ankle Surg 51:2, 2011.
56 Case Scenario #4 30yr old twisted right foot when wrestling Past medical history Closed head injury Physical examination Midfoot pain Midfoot ecchymosis Radiographs Normal
57 Case Scenario #4 30yr old twisted right foot when wrestling Past medical history Closed head injury Physical examination Midfoot pain Midfoot ecchymosis Computer tomography
58 Bone harvesting Plate placement Plate temporarily fixated Case Scenario #4 Incision placement Joint identification Trephine 2 nd TMTJ
59 Case Scenario #4 Plate fixation Plate fixation Trephine 3 rd TMTJ Plate placement Plate fixation Plate fixation
60 Case Scenario #4 Pin lateral column Pin lateral column
61 Case Scenario #4 Final post-op films
62 Surgical Goal Anatomic reduction If not anatomic Poor outcome Rapid progression to arthrosis Requires revision surgery Lawsuit
63 To Fuse or Not to Fuse? Outcome comparisons Primary arthrodesis (n = 21) AOFAS midfoot score 88.0 p < Level of activity 92% p < ORIF (n =20) AOFAS midfoot score 68.6 Level of activity 65% Revised to arthrodesis 5 Ly and Coetzee, J Bone Joint Surg 88A:3, 2006.
64 To Fuse or Not to Fuse? ORIF / No arthrodesis Study n Outcome Mulier % Ly and Coetzee % Henning % Stavlas /100 Primary arthrodesis Mulier 1 * 12 50% Ly and Coetzee % Henning % Sangeorzan % 1. Mulier, et al., Foot Ankle Int 23:10, Ly and Coetzee, J Bone Joint Surg 88:3, Henning, et al., Foot Ankle Int 30:10, Stavlas, et al., Int Orthop 34:8, Sangeorzan, et al., Foot Ankle 10:4, *- Includes partial arthrodesis
65 To Fuse or Not to Fuse? Primary arthrodesis High incidence of posttraumatic arthritis Improved results with arthrodesis 1-3 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, Sangeorzan, et al., Foot Ankle 10:4, Komenda, et al., J Bone Joint Surg 78:11, 1966.
66 Complications Risks and complications Wound complications Neuritis / CRPS Painful hardware When to remove? Non-union Mal-union Stiffness Post-traumatic arthritis
67 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?
68 Personal Preferences 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
69 Conclusions Complex injury with high morbidity Goals of surgery Sequential reduction Anatomic reduction ORIF vs primary arthrodesis
70 Annual Surgical Conference 2018 Thank You Zeeshan S. Husain, DPM, FACFAS, FASPS
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