LISFRANC INJURIES

1. LISFRANC INJURIES Gill Bayley Dr. Jaques Brunet May 26, 2010

2. Jacques Lisfranc de St. Martin (April 2, 1790 - May 13, 1847) • ‘Napoleon’s Surgeon’ • Pioneering French surgeon and gynecologist. • lithotomy in women • removal of the rectum • amputation of the cervix uteri. • Described amputations threw the TMT after a solider fell from his horse with his foot in the stir-up

3. Outline • Anatomy • Epidemiology • Mechanism of injury • Classification • Diagnosis • Treatment • Complications

4. Anatomy • TMT joint divides the midfoot and forefoot, 3 columns • Stability: 9 bones and ligaments 0.6 mm 13 mm 3.5 mm Kalia et al. Epidemiology, imaging, and treatment of Lisfranc fracture-dislocations revisited. 2010 Skeletal Radiol

5. Anatomy - Bone • Roman Arch • Trapezoidal shape of middle 3 • 2nd MT is the Keystone • Middle cuneiform is recessed proximally • Mortise = 5 Articulations • 8mm : MC • 4mm : LC • Peicha et al, 2002 • Lisfranc injuries vs cadavers • Less recess = ↑ risk Peicha et al. The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. JBJS 2002.

6. Anatomy - Ligaments • Grouped into: • Location – dorsal, interosseous and plantar • orientation – transverse, oblique, longitudinal • Transverse ligaments • MTs 2nd – 5th • Longitudinal and oblique • Network that secures cuneiform/cuboid:MT DORSAL < PLANTAR

7. Anatomy - Ligaments • Medial cuneiform anchored to 2nd MT by 3 oblique ligaments • Interosseous: LISFRANC ligament • Strongest ligament in TMT • 8-10 mm wide • 5-6 mm thick Lisfranc > Plantar > Dorsal Dorsal Plantar

8. Anatomy - Support • P. longus andTib anterior further stabilize the 1st TMT joint • Plantarfascia and intrinsic musculature of thefoot add stability

9. Epidemiology: • 1: 55 000 people • M:F 2.5:1 • High energy vs low energy • 20% are missed • more frequent in polytrauma • Becoming less common with better diagnostic modalities

10. Mechanism - Indirect • Indirect: excessive plantar flexion and/or Abduction • 1 – Ankle equinus, MTP dorsiflexion • Missed step • Player falling on another • Foot on brake compressed by floorboard intrusion • 2 – ER on pronated foot - UNSTABLE • windsurfing • Foot in stirrup (original lisfranc)

11. Mechanism - Direct • crush • Direct worse injury and outcome than Indirect mechanism • Associated with compartment syndrome and vascular compromise

12. Classification - Hardcastle • Several described, most common • Type A: Total Incongruity • Fracture base of 2nd common • Type B: Partial Incongruities • Type C: Divergent • May have extension of injury into cuneiforms or talonavicular joint

13. Diagnosis - presentation • Unable to wt bear • Swollen and tender midfoot • Widening or flattening *HAVE A HIGH CLINICAL SUSPICION* Missed Lisfranc fractures are the most common reasons for malpractice lawsuits against radiologists and emergency physicians, Chesbrough 2002

14. Diagnosis – Clinical Tests • Plantar Ecchymosis Sign • Pathognomonic • Gap Sign • Diastasis : hallux and 2nd toe • Tender along TMT joints • Passive Pronation-Abduction • Can’t WB on tip-toes • Stress Test of 1st/2nd MT – piano test Myerson et al. Current Management of TMT injuries in the Athlete. JBJS. 90;11, 2008. http://kerrymcbride.blogspot.com/

15. Diagnosis – associated injuries • Vascular injury – DP injury is rare, but possible • DP may not be palpable due to swelling • Assess for Compartment Syndrome • > 40mm Hg, or within 30mm Hg

16. Imaging - Radiographs • AP- 1st/2nd TMT • > 2mm = suspicion • > 3mm = surgery • Fleck Sign – avulsion injury (90%) • Most common injury site is 2nd MT • 30o oblique views - 3rd/4th • AP of Lisfranc joint requires with beam 15o offvertical • Lateral - alignment • Wt Bearing • If in question and possible • Stress view • ABduction-Pronation • May require anesthetic

17. Imaging – Radiographs • AP view: 1,2. 1st MTaligns with medial and lateral borders of medial cuneiform 3. 1st and 2nd intermetatarsal space continuous with medial and middle cuneiform space • On 30o oblique: 4. Medial border 4th MT in line with medial border cuboid 5. Lateral border of 3rd MT in line with lateral border of lateral cuneiform 6. 3rd and 4th intermetatarsal space is continuous with intertarsal space of lateral cuneiform and cuboid. • Lateral view 7. Should be uninterrupted line along dorsum of 2nd TMT jt (<= 1mm plantar displacement) Gupta et al. Lisfranc Injury: Imaging findings for this important but often missed diagnosis. Curr Probl Diagn Radiol, May/June 2008

18. Imaging - Radiographs < 1 mm

19. Imaging - Radiographs Lateral Oblique AP Gupta et al. Lisfranc Injury: Imaging findings for this important but often missed diagnosis. Curr Probl Diagn Radiol, May/June 2008

20. Imaging – WB Views Gupta et al. Lisfranc Injury: Imaging findings for this important but often missed diagnosis. Curr Probl Diagn Radiol, May/June 2008

21. Imaging – WB Views Gupta et al. Lisfranc Injury: Imaging findings for this important but often missed diagnosis. Curr Probl Diagn Radiol, May/June 2008

22. Imaging – WB Views • WB lat. views of both feet to assess longitudinal arch • Faciszewski et al. flattening of the long. arch is assoc. w poor px. • They compared the distance from plantar surface of med. cuneiform to 5th MT • <3-4mm difference between feet • Should never be -ve

23. Imaging - Radiographs Gupta et al. Lisfranc Injury: Imaging findings for this important but often missed diagnosis. Curr Probl Diagn Radiol, May/June 2008

24. Imaging – CT and MRI Kalia et al. Epidemiology, imaging and treatment of Lisfranc fracture-dislocations revisited. Skeletal Radiol. 2011 • CT • 3D imaging shows detail • Helps direct treatment • MRI • Subluxation • Marrow edema • Lisfranc Ligament

25. Management Watson et al, Treatment of Lisfranc Joint Injury: Current Concepts. JAAOS 18:718-728. 2010

26. Management • Good results with displacement, Xrays don’t always correlate with outcome • Brunet 1987 • No correlation between diastasis and outcome • Faciszewki 1990

27. Management • Displacement correlates with outcome • 2mm displacement decreases articular contact, increases risk of OA • Untreated sprains lead to OA

28. Management - Nonsurgical • 6 weeks in CAM boot, WBAT vs NWB • F/U x-rays at 2 weeks • 3-6 weeks of PT for gait training • Transition to supportive shoe, will take total about 4-6 months

29. Management - Surgical • Timing - Sooner is better • Skin wrinkling • Commercially available ice therapy • With-in 2 weeks • Severe – 3 weeks bulky jones • Up to 6 weeks is appropriate

30. Management - Surgical • Percutaneous • ORIF • K-wire • Cortical Screw • Arthrodesis • Ligamentous Injury – experimental techniques

31. Management - Percutanous • Under Flouro • Axial traction and pull forefoot medially • Bone clamps • Across med cuneiform and 2nd MT • Canulated Screws over guide wires • Fix Medial column • Then fix middle column

32. Management - ORIF • 1st incision centered at TMT joint and along axis of 2nd ray, lateral to EHL tendon • EHL tendon,deep peroneal nerve, and dorsalis pedis artery are identified and retracted as a unit • Deep/sharp disection to 1st/2nd TMT • 2nd incision: • between 3rd and 4th MT’s to expose 3rd TMT joint

33. Management - ORIF • K-wires for provisional stability • 3.5 or 2.7 cortical screws • 1st to Medial Cuneiform • 2nd to Middle Cuneiform • Medial Cuneiform to 2nd • If unreduced 3rd TMT; use 2nd incision: • 3.5 or 2.7 cortical screw from 3rd to Lateral Cuneiform • Reduction of 4th and 5thTMT joints usually occurs with reduction of the medial three TMT joints • secured with K-wires (rarely screws)

34. Management - ORIF • If continues to be painful post ORIF try conservative management: • Proper foot wear • Activity modification • Steroid injections • Salvage procedure is TMT Arthrodesis

35. Management - Arthrodesis • Arthodesis has better outcome than ORIF • Cotzee et al 2006 • Lower reoperation rates with primary arthrodesis • Henning et al 2009 • Higher rates of stiffness • Mulier et al 2008 • Not recommended for athletes with more subtle injures

36. Future Techniques -Dorsal Plating • Allow prolonged fixation to allow ligamentous injury to heal • Only remove if bothersome to patient • Post-operative care is the same http://compressionramp.com/LFst.html Watson et al, Treatment of Lisfranc Joint Injury: Current Concepts. JAAOS 18:718-728. 2010

37. Future Techniques - Endobutton • Cadaveric studies – similar support to screw fixation • Panchbhavi et al. 2009 • May improve outcome with more rapid return to sports • May need support with K-wire • Removed before WB • No need for removal • Post-operative protocol the same Smith and Nephew

38. Management - Aftercare

39. Complications • Injury to sup. Peroneal nerve • Injury to DP artery • Incomplete reduction • Non-union (consider vascular consult prior to OR, Smoking cessation) • Malunion  1st TMT tends to be dorsiflexed and abducted • Failed hardware, DVT

40. Conclusion • Lisfranc injuries are often overlooked • Be suspicious with any midfoot injuries • Do appropriate imaging, and stress views • Close F/U • ORIF vs. 1º arthrodesis for lig. injuries  no long term results • Missed/ mal-reduced injuries are associate w sign. morbidity

41. OITE Transverse instability of the Lisfranc joint is the result of injury to the interosseous first cuneiform-second metatarsal ligament (Lisfranc’s ligament) and which of the following ligaments? 1- No other ligament injury is necessary 2- Spring ligament 3- Plantar ligament between the first cuneiform and the second and third metatarsals 4- Long plantar ligament 5- Bifurcate ligament

42. Thank you.