Evolving technique update: how to avoid the subtle lisfranc: 8 - - PowerPoint PPT Presentation

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Evolving technique update: how to avoid the subtle lisfranc: 8 - - PowerPoint PPT Presentation

Feb 17, 2023 108 likes •578 views

Evolving technique update: how to avoid the subtle lisfranc: 8 tips in 8 minutes. Michael J Coughlin MD Co-chairman, NFL Foot and Ankle Committee Conflicts None for this talk Consultant with Arthrex, Stryker, Integra Royalties from

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Evolving technique update: how to avoid the subtle lisfranc: 8 tips in 8 minutes. Michael J Coughlin MD

Co-chairman, NFL Foot and Ankle Committee

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Conflicts

  • None for this talk
  • Consultant with Arthrex, Stryker, Integra
  • Royalties from Arthrex, Stryker, Integra,

Erchonia

  • Textbook royalties- Elsevier
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Incidence

  • Uncommon injury
  • 1 in 55,000-60,000 per year
  • 0.2% of fractures
  • 50% incidence of

postraumatic arthritis

  • Missed/delayed diagnosis

can lead to midfoot instability, planovalgus deformity, and early

  • steoarthritis
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Anatomy: Lisfranc Complex Lisfranc

Ligament

  • Intermetarsal base

ligaments exist between 2-5

  • Lisfranc ligament=
  • nly direct

stabilizing feature between base of 1st and 2nd rays

  • Interosseous and

thicker plantarly

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Lisfranc Injury Pattern

  • In the NFL, almost

70% are non-contact injuries

  • Many are not surgical

cases

  • But huge time loss

before RTP

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If you miss these, you aren’t looking very closely!

We are talking about subtle injuries

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Lateral subluxation

Hard to miss!!

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Lisfranc Injury

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Lisfranc Experimental Conditions

  • 13 limbs, 62

distinct loading events

  • Parameters

Varied: Axial load, Magnitude

  • f twist, Toe

flexion, Boundary at met heads, Axis

  • f twist, Direction
  • f axial force

vector

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Cuneiform Coordinates

Cuneiform

Cuneiform

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Lisfranc Injury Mechanism

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  • Approximately 20% of Lisfranc

injuries can be misdiagnosed or simply missed which can lead to potentially significant sequelae

Myerson et al. Foot Ankle 1986;6:225–42.

Don’t miss this injury: Steps 1-8 not to miss

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#1-Physical Examination

  • Unexplained swelling

http://www.footeducation.com/lisfranc-injury-fracture-midfoot-sprain/

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#2-Physical examination

  • Careful inspection
  • f skin and soft

tissue

  • Plantar ecchymosis

sign

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#3-Physical examination

  • Nothing beats

palpation of the foot

  • Where is the

tenderness?

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#4-Physical Exam

  • Provocative Maneuvers
  • Compression of

midfoot

  • Dorsal and plantar

deviation of the first met

  • Passive pronation

abduction

  • Squeeze 1st/2nd

interspace in coronal plane

Myerson, M, J. Bone Joint Surg., 2008

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The start!!!

  • Listening to the patient
  • And touching (examining)

the patient

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Imaging (5-8)

#5- Your first image

  • Plain radiographs are the

initial evaluation

  • 3 views
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You may see nothing!

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You may see something obvious!

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Subtle subluxation without fracture

wt bearing AP & lateral x-rays and compare to uninjured foot TC

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Subtle subluxation

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Plain Radiographs

  • May be obvious

(large bony Lisfranc fragment)

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  • The fleck sign

– Avulsion of base of 2nd met – Pathognomic for Lisfranc injury – Present in approximately 90% of Lisfranc injuries

May be a subtle fleck sign

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The Normal Foot Alignment

  • Space between 1st

and 2nd MT

  • Medial border of

2nd MT aligns exactly with medial border Middle Cuneiform

  • Medial border of

4th MT aligns with medial border Cuboid

  • Aligned TMT on

lateral views

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Mann's Surgery of the Foot and Ankle, 9th ed., 2014. Chapter 35 Dislocations of the Foot.

No dorsal stepoff

Plantar aspect of medial cuneiform is dorsal to plantar aspect of 5th met

Dorsal stepoff

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Physical Exam-leads you to be suspicious!

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#6 When in doubt Stress Radiographs

  • May be a subtle in

ligamentous Lisfranc

  • B/L Weight bearing

foot on same cassette X-ray to differentiate stable vs unstable sprain – Image

  • ppositesfoot to

compare

  • External rotation

stress X-ray

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#6--Stress Radiographs

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#7-CT scan

  • CT scan

– MRI You may see none of the se fracture patterns on plain radiographs

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#7 Advanced imaging: CT

  • Means to show
  • ccult fractures

and fracture extension into midfoot

  • Means to show

subluxed TMT (<2mm unable to be seen on plain films)

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#7 Advanced imaging: CT

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#7 Advanced imaging: CT

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#7-additional Spect scan

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Normal xray but pain

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Spect scan

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#8 Advanced Imaging MRI

  • Evaluate Lisfranc

ligamentous sprain when X-ray are inconclusive

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#8-MRI-Imaging

  • Radiographics. 2014 Mar-Apr;34(2):514-31. doi: 10.1148/rg.342125215. Evaluation of the tarsometatarsal joint using

conventional radiography, CT, and MR imaging. Siddiqui NA1, Galizia MS, Almusa E, Omar IM.

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Treatment Options

  • CRIF, ORIF, bridge plating
  • Arthrodesis
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Open Reduction with Internal Fixation

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Primary Arthrodesis

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Steps 1-4

(physical examination)

  • 1.Unexplained midfoot swelling
  • 2.Plantar ecchymoses
  • 3.Midfoot tenderness on palpation
  • 4.Provocative moves
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Steps 5-8

(imaging)

  • 5.Plain radiographs
  • 6.Stress radiographs
  • 7.CT/ spect imaging
  • 8.MRI
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References

1. Gilgenkrantz, Simone (2006). "[The Baron Guillaume Dupuytren]". Med Sci (Paris) 22 (8–9): 771–2. doi:10.1051/medsci/20062289771 2. Fischer, LP. Hist Sci Med. 2005 Jan-Mar;39(1):17-34. [Jacques Lisfranc de Saint-Martin (1787-1847)]. 3. Mann's Surgery of the Foot and Ankle, 9th ed., 2014. Chapter 35 Dislocations of the Foot. 4. Fractures and Dislocations of the Midfoot: Lisfranc and Chopart Injuries. An Instructional Course Lecture, American Academy of Orthopaedic Surgeons. Stephen K. Benirschke, MD, Eric Meinberg, MD, Sarah A. Anderson, MD, Clifford B. Jones, MD, and Peter A. Cole, MD. JBJS VOLUME 94-A d NUMBER 14 d JULY 18, 2012 5. Netter's Concise Orthopaedic Anatomy, 2nd ed., 2010. Chapter 10, Foot/Ankle 6. de Palma L, Santucci A, Sabetta SP, Rapali S: Anatomy of the Lisfranc joint complex. Foot Ankle Int 18:356-364, 1997. 7. Wiley JJ: The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg Br 53:474-482, 1971 8.

  • Radiographics. 2014 Mar-Apr;34(2):514-31. doi: 10.1148/rg.342125215. Evaluation of the tarsometatarsal joint

using conventional radiography, CT, and MR imaging. Siddiqui NA1, Galizia MS, Almusa E, Omar IM. 9. Aitken, A, Poulson, D. Dislocations of the Tarsometatarsal joint. JBJS Vol 45-A, 263. 1963 10. Fracture Dislocations of the Tarsometatarsal Joints: End Results Correlated with Pathology and Treatment Mark

  • S. Myerson, Robert T. Fisher, Andrew R. Burgess, and John E. Kenzora. Foot Ankle Int, April 1986; vol. 6, 5: pp.

225-242. 11. http://www.braceability.com/conditions/foot-orthotics/lisfranc-fracture-treatment 12. http://heelpadavulsion.blogspot.ch/2012/03/major-crush-injury-foot-with-heel-pad.html 13. J Orthop Trauma. 1996;10(2):119-22. Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. Ross G1, Cronin R, Hauzenblas J, Juliano P. 14. Peicha G, Labovitz J, Seibert FJ, et al.The anat- omy of the joint as a risk factor for Lisfranc dislo- cation and fracture-dislocation: an anatomical and radiological case control study. J Bone Joint Surg Br 2002;84(7):981–985. 15. Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg 2010;18(12):718–728. 16. Kuo RS, Tejwani NC, Digiovanni CW, et al. Out- come after open reduction and internal fixation of Lisfranc joint

  • injuries. J Bone Joint Surg Am 2000; 82(11):1609–1618.
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References

17. Ankle and foot injuries: analysis of MDCT findings.Haapamaki, Ville V • 2004 American journal of roentgenology. Volume 183. Issue

  • 3. Page 615 – 22

18. Current concepts review: Lisfranc injuries.Desmond, Elizabeth A • 2006 Foot & ankle international. Volume 27. Issue 8. Page 653 - 60. 19. Nunley JA, Vertullo CJ. Classification, investiga- tion, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med 2002;30 (6):871–878 20. http://emedicine.medscape.com/article/1236228-treatment#a1128 21. http://radiopaedia.org/cases/lisfranc-injury-2 22. Raikin SM, Elias I, Dheer S,et al: Prediction of midfoot injury in the subtle Lisfranc injury: comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Am 2009; 91: 892-899 23. Hardcastle, P.H., Reschauer, R., and Schoffmann, W.: Injuries to the tarsometatarsal joint. J. Bone Joint Surg., 64B:349-356, 1982 24. Arthrodesis Versus ORIF for Lisfranc Fractures SHAHIN SHEIBANI-RAD, MD, MS; J. CHRISTIAAN COETZEE, MD; M. RUSSELL GIVEANS, PHD; CHRISTOPHER DIGIOVANNI, MD, Orthopedics, June 2012 Vol 35, Number 6 25. Myerson, M, Cerrato, R. Management of Tarsometatarsal Injuries in the Athlete. J. Bone Joint Surg., Vol 90A-11. Nov 2008 26. Severe Lisfrancs Injuries: Primary Arthrodesis or ORIF? Thomas Mulier, Piet Reynders, Greta Dereymaeker and Paul Broos Foot Ankle Int 2002 23: 902 27. Ly, T, Coetzee, C. Treatment of Primarily Ligamentous Lisfranc Joint Injuries: Primary Arthrodesis Compared with Open Reduction and Internal Fixation. JBJS. Vol 88-A, No.3. Mar 2006. 28. Treatment of Lisfranc Fracture-Dislocations with Primary Partial Arthrodesis. Keith R. Reinhardt, Luke S. Oh, Patrick Schottel, Matthew M. Roberts and David Levine Foot Ankle Int 2012 33: 50-6 29. Arntz, C. T.; Veith, R. G.; and Hansen, S. T., Jr.: Fractures and fracture-dislocations of the tarsometatarsal joint. J. Bone and Joint Surg., 70-A: 173-181, Feb. 1988 30. http://www.amssm.org/foot_trauma_in_a_female_fo-csa-82.html?StartPos=70&Part=4 31. Marin-Pena et al. Fourteen years follow up after Lisfranc fracture-dislocation: functional and radiological results. Injury. 2012. 43(S2) S79-S82 32. Komenda, G, Myerson, M, Biddinger, K. Results of Arthrodesis of the Tarsometatarsal Joints after Traumatic Injury. JBJS. 78-A. 1665-1676. Nov 1996. 33. Granberry, WM, Lipscomb, PR. Dislocation of the Tarsometatarsal Joints. Surgery, Gynecology, and Obstetrics. April, 1962. 34. Abbasian, M.R., et al. Temporary Internal Fixation for Ligamentous and Osseous Lisfranc Injuries: Outcome and Technical Tip. Foot Ankle Int. April, 2015.