11/21/2016
LISFRANC INJURIES
FIX OR FUSE?
John Ketz,M.D.
Introduction
• Uncommon Injuries
• Highly Variable Injuries
• Trauma
• Sports
• Associated with other injuries
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Introduction
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Osseous Stabilizing Structures
• Middle cuneiform is
recessed proximally
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Ligamentous Stabilizing Structures
• Intertarsal
• Lisfranc
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Inter-cuneiform instability
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Significance of Lisfranc Injuries
• Soft tissue injury
• Minimal bony displacement may
understate ligamentous injury
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Significance of Injury
• Diagnosis is missed or delayed in up to 20% of
cases
• Litigation
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Impact of Injury
• It’s a Lisfranc until proven otherwise
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Normal x-rays
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Normal x-rays
 Lateral: A metatarsal should never be more dorsal
than its respective tarsal bone
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Imaging of Lisfranc Injuries
• Dynamic Joints
• Weight bearing radiographs crucial
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Imaging of Lisfranc Injuries
• Contralateral views
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Closed Reduction
• Urgent if impending skin compromise
• Can be blocked by tendons, ligaments, bone
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Indications for Surgery
 Ligamentous Instability
 Multiple fractures
 Displaced fractures
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Operative Treatment
Options
 ORIF
 Primary Arthrodesis
 Percutaneous pinning/screws
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Operative Treatment
• “ I always do ORIF, and then I take out my
screws
• “I always fuse the joints”
• “ I always do ORIF, but I leave my screws in”
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Rationale for ORIF
• Preserve the joints at all costs
• Do not eliminate a motion segment of the foot
• Hard to make the multiple fractures and a
fusion heal
• Traditional treatment
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Hardware
• What to use?
• Screws
• 3.5mm or 4.0mm cortical
• Cannulated screws
• Spanning Plates
• “joint sparing”
• comminution
• Tightrope
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Hardware
• Plates
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Hardware Removal?
• Indications?
• When?
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Operative Technique
Incisions
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Operative Technique
Dissection/Access
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Operative Technique
• Dissection/Access
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Operative Technique
• Dissection/Access
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Operative Technique
• Reduction/Temporary Fixation
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Operative Technique
• Where to start?
• Medial to lateral
• Lateral to medial
• Least to most comminuted
• My Preference
• Reduce any intercuneiform
instability
• Key in the second ray
• 1st, 3rd then 4th and 5th
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Operative Technique
• Internal Fixation
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Operative Technique
• Internal Fixation
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Operative Technique
• Internal Fixation
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Results of ORIF




Requires anatomic reduction
Poor outcomes
Rapid progression of arthrosis
Need for further procedures
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Alternatives to ORIF?
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Primary Arthrodesis
 High incidence of PTOA post Lisfranc injury
 Recommended primary fusion
Granberry Surg Gyn Obs 1962
 Significant improvement after midfoot arthrodesis for
PTOA
 Improved results with early fusion for PTOA midfoot
 Sangeorzan et al FAI 1990
 Komenda et al JBJS am 1996
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Rationale for Fusion
• Medial column of the midfoot functions rigidly
during gait for stablility
• “non-essential joints”
• Lateral column (4th, 5th TMT) is the mobile
midfoot segment
• One operation, one recovery period
• Fusion after ORIF is technically more difficult
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Primary Arthrodesis(PA) vs ORIF
 Ly & Coetzee JBJS 2006

Randomized prospective study, improved results in PA
vs ORIF for ligamentous injuries
 Henning et al FAI 2009

Less secondary procedures and trends towards better
outcomes in PA vs ORIF
 Mulier et al FAI 2002

Advocated for partial primary arthrodesis for medial
column
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Reduce and Pin unstable joints
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Remove pins and debride one joint at a time
Screw Fixation
Pin 4th and 5th if unstable, don’t fuse
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DO NOT fuse in situ!
Comminution
Fuse with Plates
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Post-Op
• Remove K wires at 4 weeks
• NWB Short leg cast(fusion) boot (ORIF) X 8
weeks
• Boot, gradual WB over next 2-4 weeks
• PT or HEP
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What Do I Do?
 Fusion
 High energy injuries
 Patients selection
 (IVDA, WC, obese, elderly)
 Highly comminuted joints
 ORIF
 Low energy
 Athletes, young&healthy
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Do I fuse everyone?
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Summary
• Complex Injuries with poor outcomes
• Each injury, patient unique
• Do not miss subtle injuries
• Goal of fixation  Stable painless plantigrade
foot
• Fuse vs. ORIF – still controversial
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