lisfranc fracture dislocation mr ms siddique md frcs mch orth frcs tr & orth miss e robinson...

Lisfranc fracture dislocation

Mr MS Siddique MD FRCS MCh Orth FRCS Tr & Orth

Miss E Robinson & Dr S Lyons Newcastle upon Tyne Hospitals NHS Trust

Importance of Diagnosis

• Incidence is 1 in 55,000• Account for 0.2% of all fractures • Missed diagnosis leads to poor prognosis

Anatomy

Mortise of Lisfranc

Shallow mortise > Inj

Peicha 2002 JBJS

Total Ankle Replacement

Mechanism of Injury

Axial loading (toes dorsiflexed, ankle in equinus)

Rotational forces (medial/lateral) with forced forefoot

abduction

Presentation

• Ecchymosis• Pain, swelling & tenderness • Painful passive abduction/

pronation • Midfoot instability Wt. • Dorsalis pedis absent • Compartment syndrome

Classification

Hardcastle 1982 Myerson 1986

Type A All MT Complete Displacement

Type B Partial Incongruity

One or more MT Displacement

1 Medial

2 Lateral

Type C Divergent Pattern

1 Partial Incongruity

2 Total Incongruity

Investigation

X- Rays

Fleck sign

Investigation

X- Rays

Stress Views

CT / MRI

Management Non Surgical

• Not fit for surgery

• Stress views FWB stable

• Diastasis <2mm cuneiforms & metatarsals

• <15˚ talometatarsal angle

Literature Recommendation

No role of close reduction & POP without fixation

• Up to 60% failure rate• Poor long term result

• Level IV Evidence• Jeffreys 1963, Goossens 1983

Operative Options

Close Reduction

Percutaneous K Wiring

Transarticular Fixation

Arthrodesis

Perfect closed reduction

• Diastasis <2mm

• cuneiforms & metatarsals

• <15˚ talometatarsal angle

Our preference

• Reduce & fix the intra-articular fracture without crossing the articular surfaces

• Buttress the fracture dislocation of joint with mini-plate if unstable

Open reduction & Fixation

Dorsal plate Vs Transarticular screws

Similar Ability to reduce &

Resist displacement

1st & 2nd TMTJ

Alberta et al Foot & Ankle int 2005

Not Recommended

POP Immobilisation without reduction

ORIF with K wires of 1st , 2nd & 3rd TMTJ

ORIF with Transarticular screws TMTJ

Primary Arthrodesis of 4th & 5th TMTJ

ORIF K Wiring

Cadaveric

Model

Open reduction & Fixation

Open reduction & Fixation

Open reduction & Fixation

Arthrodesis

• Unable to achieve quality reduction or stabilise without penetrating the articular surfaces.

• Rate arthritis

• 17% anatomic reduction

• 80% non-anatomic reduction

Primary arthrodesis for ligamentous injuries

41 patients 42 months follow up

AOFAS

ORIF Arthrodesis

68.6 88

Level 1 study Ly & Coetzee JBJS 2006

Arthrodesis for ligamentous injuries

Poor healing potential of ligaments

Loss of correction

Greater deformity

Degenerative arthritis

Level 1 study Ly & Coetzee JBJS 2006

Complications

• Midfoot arthritis

• Compartment Syndrome

• Complex regional pain syndrome

Outcome

• Complete reduction : complete satisfaction NO

• Initial articular damage or inadequate reduction directly correlates with OA

Arntz et al 1988

Outcome

• Precise anatomical reduction : optimal result

• Buzzard & Briggs 1998

• Poor outcome in compensation claim cases

• Calder et al 2004

Summary

• Investigate fully if suspect

• Outcome : Precise reduction

• Plate fixation : Transarticular screws

• Arthrodesis : Unable to achieve quality reduction

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