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Lisfranc Fusion

    Overview

    Learn the Lisfranc Fusion surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Lisfranc Fusion surgical procedure.
    The Lisfranc joints are an area of the foot and ankle where conservative management of even fairly arthritic joints can be very successful with an appropriately supportive orthotic and intelligent choice of shoewear.
    The Tarso-metatarsal joints however have a relatively limited range of movement even in the absence of joint damage or arthritis which means that little functionality is normally perceived to be lost if fusion surgery is required.
    Their surgical treatment most often involves fusing the medial three articulations and less frequently also (or alternatively) excising the lateral two joints. Significant flat foot deformity can be corrected through these joints if they have collapsed following a Lisfranc fracture pattern or due to chronic arthritic deformation.

    Indications

    INDICATIONS.
    –Symptomatic arthritis of Lisfranc joints 1-3 that has failed to settle with conservative management
    (the 4th & 5th joints if similarly afflicted normally are treated with excision arthroplasty)
    –As primary treatment for a Lisfranc fracture-dislocation when the articular surfaces are beyond meaningful reconstruction.
    SYMPTOMS & EXAMINATION.
    The symptoms of arthritis through these articulations is often well tolerated in its early stages and even when advanced can in many cases be managed conservatively. Symptoms will be well localised to the joints effected and progress along the lines of most arthritis with initially pain on extended activity eventually occurring after shorter periods of activity and then at rest and night. Not all cases of course will progress .Some patients will present with solely impingement type symptoms from the dorsal aspect of the midfoot due to osteophytes with little or no arthritic pain.
    On examination minor deformity is common with very obvious dorsal midfoot prominences visible in most patients given the sparse soft tissue cover of this part of the foot.
    The range of movement through healthy Lisfranc joints is often fairly minimal and reduction in their range of movement can be difficult to be sure on. Examination of the joints by axially loading them and moving them is likely to elicit pain which will localise well to the joints effected. The lack of much range of movement through the normal Lisfranc joint means that if they do require fusion then function ( and composite foot & ankle plantar/dorsiflexion) is usually little effected following a sound arthrodesis.
    Less common is a midfoot collapse resulting in a plano-valgus deformity though this should be considered as a possibility in all unilateral plano-valgus presentations. This occurs not simply as a post-traumatic event but may simply represent a gradual ,progressive arthritic deformity. Correcting such a plano-valgus collapse if chronic and associated with bony deformity and loss of bone structure will require either truncated wedges of tri-cortical graft into the Lisfranc joints or using locking dorsal wedge plates with graft substitute or morcellised bone graft. Both techniques can produce plantar-flexion through the arthrodesis sites and thus correct such deformity(see clinical photographs in imaging section). The medial longitudinal arch can be entirely corrected through the medial joints. It is key in these cases that an assessment of the degree of mid foot supination (if any) is also made and this is inter-currently corrected at the time of fusion also. In severe plano-valgus deformities the Achilles tendon may be tight and this should be assessed.
    Lisfranc arthritis may also co-exist with a Cavus foot but will not be the cause of the deformity.
    One aspect of the deformity associated with Lisfranc arthritis that is difficult to improve completely is significant bony hypertrophy at the medial aspect of the first Lisfranc joint. The insertion of the Tibialis anterior limits how much bone can be debulked from this region.
    INVESTIGATION.
    Whatever form of imaging is used careful assessment of the joints proximal to the Lisfranc articulations should be made as these on occasion need to be included within the fusion , for reasons of co-existing arthritis , deformity correction or both.
    X-Ray: Both AP and Lateral projections can be difficult to interpret clearly with respect to the extent of midfoot arthritis due to the relative overlap of these articulations . Oblique imaging can assist but more objective is a CT scan or MRI.
    CT Scan: Whether a case is acutely post traumatic and a clear assessment of the alignment of the metatarsals and articular surface damage is required and or chronically arthritic and the most objective view of severe arthritis prior to considering fusion is required a CT is for many the investigation of choice. MRI is more difficult to interpret clearly on both counts , though does have advantage in detecting early degenerative change .Clinicians preferences vary and MRI is also appropriate.
    Ultrasound: This is of use for diagnosis and in conservative management for placing injections precisely into joints under question.
    NON-OPERATIVE MANAGEMENT.
    The usual measures of activity modification and anti-inflammatory medications are indicated.
    A custom made rigid Orthotic and appropriate stiff soled and rocker profile shoewear (for example hiking boots) are a useful starting point .Shoewear with built in shock-absorbtion such as fit flops can also assist.
    Ultrasound guided injections can help in addition to the above measures and are of use in both the more acutely presenting painful patient as well as more chronic cases.
    ALTERNATIVE OPERATIVE MANAGEMENT.
    Dorsal Exostosectomy: Some patients will present with solely impingement type symptoms from the dorsal aspect of the midfoot due to osteophytes with little or no arthritic pain. There is a role for simple (& conservative) removal of exostosis in such cases ,though a chance that as a result more deep seated arthritic pain may occur. There is no role for a more general debridement of arthritic Lisfranc joints as a precursor to fusion surgery.
    Excision arthroplasty: If the 4th and 5th tarsometatarsal joints are also effected by significant and symptomatic arthritis these are excised rather than fused.
    CONTRAINDICATIONS.
    Conditions that compromise soft tissue or bone healing need to be optimised.

    Setup

    GA or regional anaesthesia
    Femoral & sciatic blocks for post-operative pain relief
    Laminar flow , peri-operative antibiotics , 2-4 weeks of post operative LMW Heparin
    Thigh tourniquet and Flowtron on contra-lateral calf
    Ankle positioned into neutral using sandbags & side supports
    Large , rolled up sterile towels behind the ankle to improve access for cuts.

    Operation

    The skin incision is between the first and second metatarsals(1) extending proximal and distal to the Tarso-metatarsal joints. During blunt dissection through the fat layer during the deep Peroneal nerve may be encountered and should be avoided. It has a number of branches at this level. The Extensor Hallucis longus(EHL) tendon is located medially(2) and lies in its sheath. The skin edges must not be undermined.

    The EHL(1) has been exposed by opening its sheath (2) The Extensor digitorum brevis tendon(3) and muscle is then identified laterally . Between these two extensors lies the neurovascular bundle(usually). Occasionally it lies lateral to the short extensor.

    Once the vessels and nerve are identified(2)they need to be isolated from the underlying bone. This is done with a combination of sharp and blunt dissection. On their plantar aspect they tend to be firmly adherent and require careful sharp dissection off the bone with a cuff of deep fascia.The tendons to the hallux are retracted.
    The soft tissue envelope is thin and liable to poor healing so the self-retaining retractors need to be frequently detensioned and used carefully.

    The neuro-vascular bundle(2) adequately mobilised to allow access to the underlying MTC articulations(3) for preparation.The short extensor lies laterally(1).

    The bundle passes plantar-wards between the base of the 1st and 2nd Metatarsals and will need to be very carefully mobilised here. The vessels are small , fairly immobile and easily damaged especially in this area. If bleeding is encountered use bipolar diathermy sparingly and under direct vision. A coagulating gauze such as Kaltostat can be useful here applied topically (but sparingly) to bleeding points.

    The base of first metatarsal(1) and medial cuneiform (2) sub-periosteally dissected, with the neuro-vascular bundle avoided(3). There is clear incongruency here between the 1st Metatarsal base and the medial Cuneiform in this post traumatic case. This is the correct general level of subperiosteal exposure and it needs to proceed laterally as well.
    Some more proximal exposure is going to be required to identify the location of the Navicular-Cuneiform articulations so they can be avoided when fixation is placed.
    Distally one needs to go well beyond the metaphyseal to diaphyseal junction of the 1st Metatarsal if screw fixation is going to be used to allow appropriate placement of the retrograde screw from 1st metatarsal to medial Cuneiform.

    The 1st metatarsal base(1), medial cuneiform(2), second metatarsal base(3), intermediate cuneiform(4) and distal extent of navicular(5) are adequately exposed.
    At this stage the extent of the dorsal osteophytes will be evident. As a first step in preparation these should be removed with fine osteotomes and kept for subsequent use as graft at the time of fixation.

    The medial approach may only allow adequate access to the first and second metatarsals(1-2) and their cuneiforms. Preparation of the 1st MTC joint is further helped by a limited and subperiosteal dissection of some of Tibialis anteriors’ insertion medially(3). This is into the 1st metatarsal base as well as medial Cuneiform
    By extending the length of this incision and centring the incision slightly more laterally it can however be possible to access all 3 medial joints in some patients.

    A second incision is often required to access the third metatarsal(1) and lateral cuneiform(2).This is in the line of the third metatarsal and proceeds through the distal extent of the Extensor Digitorum Brevis(EDBr) muscle belly.

    If the 4th and 5th TMT joints need to be excised these can also be approached through the same (though lengthened) lateral incision. The Sural nerve may be encountered though tends to run in the fat layer at the level of the 4th and 5th Metatarsals.
    The clearance across these joints should be complete with no bone spanning the articulation. The joints should be excised using an appropriate sized osteotome to yield decent sized excised bone blocks. These can then be used if required as graft (potentially even structural graft) into the medial Lisfranc articulations. Structural graft otherwise should be taken from the same side Iliac crest.
    Interposition of soft tissue into this excision arthroplasty is described but in reality there often is little substantial here to allow interpose. Sewing any of the Extensor Digitorum Brevis into the gap changes the lateral profile of the foot without obvious symptomatic advantage.

    Preparation of the joints is easiest done using a high 5mm speed burr(1) , a small pair of laminar spreaders(2) to assist access and a set of fine Lambotts osteotomes. It is important to prepare all articulations ,including those between the Metatarsals and those between the Cuneiforms.
    Too much (& differential amounts of) resection should be avoided as this will make congruent joint reduction difficult. It should be remembered that the joints are fairly deep (measuring dorsal to plantar) and preparation should be all the way to to their plantar aspect (but not beyond). Failure to do this may make reduction and compression of an articulation impossible.
    As always with preparation for any fusion a balance needs to be struck between getting back to healthy bone surfaces and leaving enough bone to permit good bone to bone contact for fixation. This can be a particular issue in Lisfranc fusions as many articular surfaces with slightly varying orientations and degrees of arthritic change are prepared.
    In short during preparation one should be careful not to remove too much bone from the articulations in pursuit of the perfect subchondral bone and reference should always be made to the other articulations being prepared to ensure an appropriate balance is achieved .
    It is a useful routine at the end of preparation to drill extensively into the joint surfaces with 1.6mm K wires to open out any subchondral bone plates that have not been fully removed.
    All bone swarf/debris should be carefully “harvested” and kept in a moist swab ready for packing into any small gaps left after fixation.

    Once the joints have been prepared the midfoot in this area is fairly unstable. Repositioning it accurately (and correctively) prior to fixing it is as important as every other stage in the operation.
    An initial guide wire is placed from medial cuneiform (1) to the base of the second metatarsal (2) with the joints held in an appropriate position. Further wires are then placed across the medial 3 articulations. Attention is paid to both alignment and bone to bone contact.
    Once position is confirmed with Image Intensifier of the initial wire to the 2nd metatarsal base a 4.0mm cannulated titanium screw is routed along the wire after drilling.

    Placing the screw and compressing the second metatarsal base onto the medial cuneiform narrows any
    splaying of the 1/2 inter-metatarsal space. Thought needs to be given after this initial key fixation to the where each subsequent screw or staple will sit (prior to their drilling and implantation) as there is limited space for fixation.
    If correcting a planus deformity an opening wedge plate may be applied dorsally or truncated wedges of structural bone graft inserted dorsally. These should be applied prior to placement of the fixation into the 2nd Metatarsal base.
    One effect of lengthening the dorsal aspect of the metatarsals with any form of wedge is to stretch the dorsal soft tissue envelope and so the size of dorsal wedge used should be judged carefully.

    If using the screw fixation technique then a screw from the first metatarsal (1) to the medial cuneiform (2) is the next to be placed. This is best done with an entry hole burred at the dorsal aspect of the Metaphyseal Diaphyseal junction into the thick cortical bone. This is to allow correct angular positioning of the drill and subsequent screw head . It also minimises the risk of fracturing through this dorsal cortex as the screw is being seated.
    See the imaging section for the sequence and location of screws used for fixation.
    Alternatives for fixation are a combination of screws and dorsal compressive staples or dorsal plates.
    Any gaps evident at the arthodesis sites should be packed with autograft from removed exostoses and bone swarf from burring . Allograft is also an option here.

    Pre-operatively it is best to assess the extent of mid foot degenerative change using a CT scan. If the lateral (4th & 5th TMT) articulations are involved these can be inter currently excised. If the degenerative change is more proximal then the fusion can be extended .
    In this case there has been a divergent 1/2 TMT injury which has not been primarily treated.
    The fusion has corrected this divergence and the associated arthritic change.

    Screws alone can be used for fusion but finding room for placement can be an issue intra-operatively
    The order of screw insertion is shown on the right hand image. The tip of the K wire is plantar (& left by a previous surgeon with no ill effect).

    It is routine & best practice to identify the extent of mid foot arthritis using CT.
    Plain X-ray lacks accuracy due to the overlay over the various mid foot articulations on each other. Not only are the Lisfranc articulations best identified but so are the more proximal articulations which may on occasion require inclusion into the fusion mass.
    As the CT is a non-weight bearing investigation the extent of deformity is not necessarily as well shown as with a weight-bearing X-Ray.
    On this saggital view the 2nd & 3rd MTC joints are clearly degenerate

    The coronal CT shows a fairly typical arthritic distribution effecting the 1st through to 3rd MTC joints.

    Fusion in this case has been using a combination of locking dorsal opening wedge plates( to correct a planus deformity through these joints) as well as a few Charlotte staples(Wright medical).
    The plates have a dorsal “box”section which produces relative plantar-flexion of the distal metatarsals (thus improving Longitudinal arch profile) but also result in a gap that needs to be filled with graft.

    Fusion in this case has been using a combination of locking dorsal opening wedge plates( to correct a planus deformity through these joints) supplemented by Wright Charlotte staples. The plates do have a dorsal “box” but also produce a gap that needs to be filled with graft. Wright Allomatrix putty works well.
    Due to the size of plates available it is often difficult to fit three and the 3rd TMT joint has been fixed with a Charlotte staple.

    Clinical photograph of a midfoot collapse secondary to loss of the normal Lisfranc joint alignment caused by chronic arthritic change.

    Frontal image of the same foot. Note the fairly normal hindfoot alignment despite loss of the medial longitudinal arch.

    The same foot following corrective fusion of the medial 3 Lisfranc joints using Iliac crest graft and a dorsal plating system.

    The significant improvement in medial arch profile is far more noticeable post-operatively in the sagittal plane.

    Post Operative

    2 weeks in back-slab , dressing changes at 1 & 2 weeks
    Complete cast between weeks 2 to 6 & non-weight bear
    Check X-ray at 6 week stage (AP & Lateral projections).
    Patient depending into long post-operative boot and gradual increase in weight-bearing at this stage.For poorer bone quality patients or possible compliance issues continue in a walking cast until 12 weeks.
    Add an “off the shelf” supportive , semi-rigid 3/4 length orthotic to be used once in post-operative boot and until return is made to normal shoe wear. An alternative is a patient using previous custom made rigid devices if these are comfortable.
    A further AP & Lateral X-Ray is indicated at 12 weeks. If this is equivocal in terms of bony union ( and there is clinical indication) then an oblique view may be required. If there still remains a question about union then from 12 weeks onwards a post-operative CT for the most definitive .
    May be comfortable enough to make transition into stiff soled walking boot by 12 weeks.
    Remain in this for all weight bearing for a further 6 weeks. Heavy manual tasks to be avoided until 5 months post-operatively.

    Recommended Reading

    Treatment of primarily Lisfranc joint injuries :Primary arthrodesis compared with open reduction and internal fixation.
    J Bone Joint Surg.2006.88-A:514-520
    T.V.Ly , J.C.Coetzee
    41 patients in an RCT comparing either ORIF or medial (1-3)TMT fusion for Lisfranc injuries(approximately equal numbers in each arm). Follow up was an average of 3 1/2 years.
    Better functional results at two years with primary fusion( patients estimated that they were over 90% of their previous functional level as opposed to over 60% in the reduction group) .No further operations in the primary fusion group . 25%of the patients in the ORIF group required fusion within the study period.
    The diagnosis and treatment of injury to the tarsometatarsal joint complex.
    J Bone joint surg.1999.81-B:755-763.
    M.S.Myerson
    A good review article
    Salvage of Lisfranc’s tarsometatarsal joints by arthrodesis
    Foot & Ankle 1990. 10. 193-200.
    B J Sangeorzan ,R G Verth, S T Hansen
    16 patients with pain and 12 with associated deformity . All treated by screw fixation after formal joint preparation.
    Good or excellent results in 70% and fair or poor results in 30%.
    A total of 49 joints were arthrodesed in the 16 patients and a total of 4 of these went on to non-union.
    Full text at :http://journals.sagepub.com/doi/10.1177/107110079001000401
    Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries
    J Bone Joint Surg (Am). 2016:98(9).713-20
    V Dubois-Ferriere et al.
    61 patients reviewed retrospectively up to 24 years after treatment which was a fusion only if the injury was not primarilty reconstructable with screws.
    Mean visual analogue pain score 2.5. Arthritis was present in 2/3rds of patients though it was symptomatic only in just over half of cases.



    Reference

    • orthoracle.com

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