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Lisfranc fixation for fracture-dislocation injury

    Overview

    Learn the Lisfranc fixation for fracture-dislocation injury surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Lisfranc fixation for fracture-dislocation injury surgical procedure.
    Fracture-dislocations of the tarso-metarsal joints are collectively given the eponymous name of Lisfranc injuries. In fact, the name Lisfranc only applies to the exceedingly strong plantar ligament that binds the base of the second metatarsal to the medial cuneiform. Invariably, this ligament is injured in a wide spectrum of injuries ranging from pure ligamentous injuries to multiple, comminuted fracture-dislocations of the tarso-metatarsal complex. Therefore, these injuries are difficult to meaningfully classify and there is no one surgical method to reconstruct them. Debate remains regarding the role of open reduction and internal fixation versus primary fusion or a combination of the two techniques. What seems to be true is that restoration of anatomy with either philosophy leads to the best results. Therefore, it is important that the surgeon can fully appreciate all injured structures and deal with each of them when reconstructing the midfoot.

    In this case, a 24-year old rugby player sustained a closed injury to his left foot during a game. He described his toes being fully planted on the ground with his heel in the air when an opponent fell heavily onto the heel and the foot twisted. He presented with a swollen, painful foot through which he found it difficult to bear weight.

    Indications

    INDICATIONS
    An acute, unstable, injury to the tarso-metatarsal complex. Instability may be implied by the sheer displacement of the bony fragments. In spite of many quoted classification systems within the literature, none has proven useful either as a tool to aid in planning surgical management or in helping to determine the outcome from these injuries. Arbitrarily, the definition of an acute injury is one of less than 4 weeks old. In patients presenting later than this, there is a much more cogent argument for primary arthrodesis rather than open reduction and internal fixation.
    SYMPTOMS & EXAMINATION
    The classic triad of symptoms and signs in a tarso-metatarsal injury are pain, significant swelling and an inability to bear weight. This triad has to be in the context of a significant mechanism of injury. The three main mechanisms of injury are:

    During sporting activities, the patient describes torsion of their body around a fixed, planted foot. This fits with the mechanism described above and accounts for the observation that the injury can occur when a horse rider is twisted out of the stirrups.
    A large individual, often in unstable shoes (such as high heels), twists their midfoot on the kerb or an uneven piece of ground.
    A direct crushing force applied to the dorsum of the midfoot.

    The patient often indicated the source of the pain to lie in the dorsum of the midfoot. Swelling is usual and persistent. On the sole of the foot, there may be a characteristic D-shaped bruise under the medial arch. With knowledge of the surface anatomy of the bones and joints of the foot, tenderness can be localised to specific parts of the tarso-metatarsal complex. In some instances, the joints may be subluxatable and in fixed dislocations, the soft tissue envelope may be threatened as evidenced by blanching of the skin or an open injury.

    Clearly, the neurovascular status of the foot needs to be assessed.
    IMAGING
    Plain radiographic imaging is the initial mode of imaging. Three views are taken: dorso-plantar, oblique and lateral. In some instances, if the patient is amenable and the plain film images reveal subtle or equivocal findings, weight-bearing views are helpful. My personal view, and that of my colleagues in Sheffield, is that a CT scan is mandatory. This helps detail the injured structures and aids in planning surgical approach and methods of fixation. CT demonstrates small bony avulsion fracture fragments and can imply foot instability by showing joint incongruity. MRI is of benefit in assessing pure ligamentous injuries.
    ALTERNATIVE OPERATIVE TREATMENT
    Opinions vary as to the differing roles of open reduction and internal fixation versus primary fusion. Agreement between surgeons reflects the need to reconstruct foot anatomy as accurately as possible.

    My view is that pure ligamentous injuries, which are uncommon, appear to benefit from primary fusion. The vast majority of tarso-metatarsal injuries respond well to anatomic reduction and stable internal fixation. The caveat to that is the presence of comminution or severely bruised articular cartilage because in both of these instances, the high levels of energy imparted to the joints mean that the cartilage is incapable of making a functional recovery. In these instances, fusion is warranted.
    The role of percutaneous fixation for these injuries is limited because the subtle nuances of achieving accurate reduction can be difficult to appreciate under fluoroscopic views alone.
    Stable fixation means the use of strong hardware such as plates and screws with K-wires used as intra-operative reduction tools, occasional stabilisation of the lateral column of the foot, or in damage limitation surgery for polytrauma.
    NON-OPERATIVE MANAGEMENT
    Non-operative intervention has a role to play in the stable foot with no displacement of fracture fragments. In my opinion, this decision is aided by an examination under anaesthesia whereby the foot is manipulated and stressed whilst being imaged fluoroscopically.
    CONTRAINDICATIONS
    Be very aware of the red, swollen and unstable foot with little pain. This presentation should raise the suspicion of a neuropathic foot undergoing a Charcot process.

    Open incisions to the traumatised foot in the presence of diabetes, vascular disease or metabolic compromise from steroid treatment are relative contra-indications for surgical intervention.

    Setup

    The patient is positioned supine on the operating table and may require a sandbag under the ipsilateral buttock so that the foot points vertically towards the ceiling. Fluoroscopy should be available with an image intensifier and a trained radiographer. An examination under anaesthesia can be performed to confirm the surgical approach.

    Appropriate antibiotics are administered intravenously and a thigh tourniquet and exclusion drape are applied so that the knee is freely visible and mobile. Surgeon choice may mean that the tourniquet is not inflated. The limb is prepared with Chlorhexidine from toes to tourniquet.

    Operation

    Assess the injured structures with CT imaging.
    Axial CT scan showing the diastasis between the base of the second metatarsal and the medial cuneiform. There is a tell-tale fleck of bone corresponding to the location of the Lisfranc ligament, suggesting that this ligament is incompetent.

    Examination of the sole of the foot reveals the bluish discolouration of the ecchymosis generated by haemorrhage around the strong plantar ligaments around the medial longitudinal arch.

    The skin incision is marked to align along the dorsal of the first webspace.The surface landmarks of the first webspace are palpated proximally. The bases of any unstable metatarsals are palpable if very unstable. The planned skin incision is marked on the dorsum of the foot with a marker pen. This skin incision is extensile allowing access further medially or laterally to access both the entire dorsum of the medial cuneiform or the 3rd tarso-metatarsal joint respectively.

    Cauterise prominent dorsal veins immediately deep to the skin incision.The skin is incised and care is taken to cauterise the large veins that traverse the dorsum of the foot.

    Identify the tendon and muscle belly of extensor hallucis brevis.Having incised the deep fascia, the structure to identify is the tendon and muscle belly of extensor hallucis brevis. This is because the neurovascular bundle lies immediately deep to the muscle belly.

    Mobilise the tendon and muscle belly of extensor hallucis brevis to create “windows” of access medially and laterally.This muscle belly is mobilised so that the surgeon has access to windows both medially and laterally to the muscle/tendon unit by retracting the structure accordingly.

    The neurovascular bundle can be identified immediately deep to extensor hallucis brevis.By gentle lateral retraction of the Extensor Hallucis Brevis (EHB) muscle belly, the neurovascular bundle, consisting of the dorsalis pedis artery and the medial branch of the deep peroneal nerve, is appreciated and can be protected.

    Incise the injured joints through longitudinal incisions.The haemarthroses of injured joints are then often apparent and the surgical approach is directed to incise these areas through longitudinal incisions. It is only by inspecting these joints fully can decisions be made about the degree of injury to articular cartilage and also, they can only be properly reduced under direct vision.

    With the neurovascular bundle protected, the injured joints can be exposed. In this case, the Hohmann retractor is placed between the medial cuneiform (A) and the second metatarsal base (B) and clearly shows the diastasis between the two bones. Additionally, the Adsons tissue forceps lie in the widened interval between the medial (A) and intermediate cuneiforms (C). D is the base of the first metatarsal. Examination of each of these joints will reveal the level of instability from the injury. When unstable, the intercuneiform joint behaves like a piano key when pressed or elevated.

    Reconstruct the Lisfranc injury from proximal to distal.I prefer to work from proximally to distally when reconstructing foot trauma cases. Therefore, the medial intercuneiform joint is reduced and then held with a percutaneously placed guide wire for a cannulated screw. In my opinion, the optimal requirements from a cannulated screw used for fixation of these injuries should be 4mm in core diameter with a choice of thread lengths.

    Reduce and hold the medial inter-cuneiform joint.The positioning of this guide wire is checked on image intensifier. By keeping the wire within the lateral extent of the intermediate cuneiform, the length of screw can easily be measured by placing the cannulated measuring guide over the wire so that it engages with the medial cortex of the medial cuneiform. In addition, with the guide wire in situ, the paint key instability will be abolished.

    Once happy with the guide wire positioning, the wire is over-drilled and an appropriate length cannulated screw and washer are applied across this joint.

    Remember that the cuneiforms are appropriately named such that in the transverse plane, they are wedge-shaped. The medial cuneiform is significantly larger than its neighbours. Their dorsal surfaces form a gentle arc and their plantar extent is the “point” of the wedge. This means that screws applied from one to another are best placed more dorsally. The image intensifier is used to make sure that no screw threads are inadvertently placed in the lateral inter-cuneiform joint when restoring the relationship between the medial and intermediate cuneiforms. This is best appreciated by taking various oblique views of the foot.

    Check the position of the guide wires fluoroscopically.It is worthwhile demonstrating how I take intra-operative images using the image intensifier. You can appreciate why the whole of the operated limb is prepared up to the level of the tourniquet. This allows the foot to be placed in any required position by bending the knee and utilising hip rotation.
    Firstly, to take the DP view, the knee is fully flexed and foot is planted on the operating table with the intensifier appropriately positioned.

    Secondly, the oblique view is taken. This is done by keeping the knee flexed and allowing the hip to internally rotate so that planted foot lies in an oblique position relative to the intensifier.

    Lastly, for a lateral view, the knee remains flexed and the hop is fun externally rotated so that the lateral border of the foot is planted on the operating table.

    Reduce the second metatarsal against the medial and intermediate cuneiforms. Pass a guide wire from the base of the second metatarsal into the medial cuneiform.The base of the second metatarsal is then reduced against the medial cuneiform. This is often aided by using a pointed tenaculum forceps. Once reduction is achieved, I prefer to apply screw fixation from the lateral flare of the second metatarsal base across to the medial cuneiform. Therefore, my guide wire is passed percutaneously and under direct vision to the flare and then advanced into the medial cuneiform.

    The rationale for this method is that the screw head engages into the flare of the metatarsal and buttresses the base of the second metatarsal into the medial cuneiform. This is a much more biomechanically sound way of reduction. The more conventional teaching of passing a screw from the medial cuneiform into the base of the second metatarsal relies on the screw threads pulling the bone into its reduced position. A note of caution is that this technique should be used carefully if there is any bone loss or comminution of the second metatarsal base.

    Check the reduction of the second metatarsal base fluoroscopically.The position is checked on the image intensifier and the wire measured for the correct screw length.

    Measure, over-drill and then apply a part-threaded cannulated screw across the guide wire.My tip is that once the correct screw length has been selected, the wire should be advanced so that it passes through the medial skin of the foot and can be secured with an artery clip so that the wire does not come out in the process of over-drilling as it can be difficult to find its previous track.
    The wire is then over drilled and a screw is placed across the reduced joint. In this case a washer is not recommended. This is because the washer will try and sit flush with the metaphyseal flare and will not allow the screw head to seat itself properly on the cortex of the lateral flare of the second metatarsal base.

    The reduction is then checked under direct vision and checked for restoration of stability. The previous diastasis between the medial (A) and intermediate cuneiforms (C)has been reduced and the second metatarsal base (B) is now reduced against the medial cuneiform (A).

    Check the reduction and position of all hardware fluoroscopically.Final intensifier views are taken in all planes (DP view).

    Final intensifier views are taken in all planes (oblique view).

    Close the fascia and then skin.The fascia is closed with 2/0 vicryl.

    Apply a temporary cast made of plaster of Paris slabs.Subcuticular closure proceeds with a 3/0 monocryl suture. The wound is dressed with Jelonet and dressing gauze. A crepe bandage is applied over two plaster of Paris slabs. (One slab is stirrup shaped and the other is a pure back slab.)

    Post Operative

    The patient is placed in a below the knee back slab for the first two weeks after surgery. At two weeks, the wounds are inspected and re-dressed and a complete, lightweight below-the-knee cast is applied for a further four weeks. Weight bearing is not permitted for the first six weeks after surgery and in my practice, rivaroxaban is prescribed for this duration to reduce the risk of thrombo-embolic events.
    At six weeks, the patient can commence weight bearing in a walker boot which can be removed for sleeping. Basic ankle range of motion exercises are encouraged.
    At twelve weeks, the foot is assessed radiographically with standing views in three planes before abandoning further immobilisation. At this stage, physiotherapy can be helpful in mobilising the ankle and hind foot joints.
    If surgery is planned for removal of hardware, then further imaging with CT will help assess for fracture union before proceeding. In my experience, this secondary surgery rarely occurs before 16 weeks after the index surgery.

    Recommended Reading

    Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Foot Ankle 1986; 6(5): 225-42.
    This seminal and oft quoted paper has an excellent figure showing clear correlation between greater accuracy or reduction and improved clinical outcome. It suggests that there is no role for the use of Plaster of Paris management as this method of treatment is not associated with favourable outcomes. Equally, the paper suggests that closed reduction and internal fixation methods have less favourable outcomes compared to open reduction techniques. It should be borne in mind that the paper was assessing radiographically visible displaced injuries and that more subtle injuries may not have been included in the study.
    Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. Ly TV, Coetzee JC. J Bone Joint Surg Am 2006; 88(3): 514-20.
    This excellent randomised controlled trial concludes that a primary arthrodesis of ligamentous Lisfranc injuries affecting the medial two to three rays appears to give better short to medium term outcomes compared to treatment with open reduction and internal fixation.

    Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. Rammelt S, Schneiders W, Schikore H et al. J Bone Joint Surg Br 2008; 90(11): 1499-506.
    This cohort study compared the treatment between two groups of patients treated either with primary open reduction and internal fixation or salvage arthrodesis. It demonstrated that there was greater functional and patient satisfaction in those treated with primary open reduction and internal fixation in spite of significant complications affecting small numbers in both treatment groups.

    Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Henning JA, Jones CB, Sietsema DL et al. Foot Ankle Int 2009; 30(10): 913-22.
    This prospective randomized study compared groups of tarso-metatarsal fractures & fracture-dislocations treated either with primary open reduction and internal fixation or primary arthrodesis. Although there was a significant difference in the re-operation rate between the two groups such that the former group had a higher need for hardware removal and secondary arthrodesis, there was no real difference in outcomes between the two treatment arms.
    Arthrodesis versus ORIF for Lisfranc fractures. Sheibani-Rad S, Coetzee JC, Giveans MR, DiGiovanni C. Orthopedics 2012; 35(6): 868-73.
    This systematic review looked at the best quality research papers published comparing the results of primary arthrodesis and open reduction and internal fixation for tarso-metatarsal injuries. Based upon only 6 suitable studies, it concluded that both procedures give satisfactory and equivalent results, stressing the need for anatomic reduction.

    Reference

    • orthoracle.com

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