Hello, there. My name is Tom Harris. I'm interested to be able to talk to you about Liz Frank injuries and discussing beyond fixing and fusing. The disclosures here are a consultant for Arthrex and royalties from different companies. Nothing particularly significant to this talk per se, although there is one plate that I designed that I will show you. Who was this Frank? Was he a gynecologist? Was he French? Hated and unpopular in his day? Did he work with Napoleon? Well, as is often the case, the correct answer here is all of the above. And this is why you have to pay attention to this talk because about 20% of these are missed. And if you're in Minnesota, there's actually a Minnesota Liz Frank fracture lawyer out there looking for you to miss these. So the overview of this talk beyond fixing and fusing, we're going to talk a little bit about prognosis, diagnosis, stress views, particularly specific injury patterns, whether or not we should fix or fuse these. Where are your incisions going to be if you do decide to fix or fuse these? And what types of plates and screws should we be using? Also, what type of fixation should we rely on? Flexible fixation? And lastly, when can a patient or specifically an athlete return to sports? And this talk was based on recent articles in the last three to four years. So an overview of this is a 0.2% of all fractures. It happens more commonly in males than females, happens most commonly in the third decade of life. There's the direct injuries that are crushing motor vehicle accidents or fall from heights, as well as the indirect, which is the so-called sports Liz Frank injuries and hyper plantar flexion of the midfoot. And as you can see in those x-rays, there's a wide range of severities of Liz Frank injuries. So when we talk about prognosis, this was an interesting study from earlier this year out of Spain, and they looked at subtle low energy Liz Franks and they followed them for over four years. And these were fixed, not fused. And they noted flattening of the arch in 43% of patients, CRPS in 29% of patients, although they all resolved and chronic pain with an average pain score of four in almost three quarters of the patients. So the prognosis isn't great. And diagnosis wise, you need to have a high index of suspicion for these subtle injuries. And the magic number seemed to be about two millimeters of diastasis between the second metatarsal and the medial cuneiform. Weight bearing radiographs, well, we always like to get those, but they can be deceiving. And I've seen certain type of Liz Frank injuries almost self-reduced with weight bearing and patients will often stand on the lateral side of their foot. They'll just kind of protect the foot and it's hard for them to do full weight bearing on that medial column. So you've got to watch out for supination or overlap of the lesser metatarsals. Sometimes these low energy ones will, as I mentioned, auto or self-reduced. So I think that stress views are superior. Having said that, this study from four years ago out of Korea showed that 90% of cases of Liz Frank injuries had at least a minor abnormality at the medial cuneiform and second metatarsal on non-weight bearing views. You just need to have a high index of suspicion. So these can be discovered on non-weight bearing films. And here's some examples that they have from their paper with some widening there that you'll see at the Liz Frank area. Another thing they noted was this loss of parallelism that you can see on the oblique view and that second metatarsal. You lose that parallelism as another sign of a relative Liz Frank injury. Stress views, as many as 10, 15 to 20% of these can't be seen without stress views. It can be painful for the patient. It's kind of hard to do in the office, especially if it's the right foot. Two millimeters seems to be the magic number, but this is debatable. It can go up to five millimeters in some circles. For me, if I have a high index of suspicion, I'll do these in the OR with the patient consented for a potential ORF. And that way you could skip the CT scan or the MRI. And here's an example of a stress view. You can see there's a large base of the second metatarsal fracture there. However, with stress, that first metatarsal really opens up. And that's something I often see, and that has certain implications for fixation. This was a nice study from injury, and this was 2021 and 18 weeks out from injury in this patient. The patient had pain at the medial first TMT joint, and they called this the so-called Liz Frank jut, which was prominent and visually apparent. And you can see that prominence of that medial column just collapsing. So look out for that Liz Frank jut if you are seeing these in diagnosis. This was a nice study out of Utah and Dr. Saltzman's group, and they noted a relatively widening from C1 to M2 greater than 1.5 millimeters under partial weight bearing could indicate a complete injury. A complete transection of the inner cuneiform ligament was required to see a diastasis of more than 2 millimeters. So this is a complicated study, but it made me think that there are more than just a simple ligament being torn here. There's a lot of complex plantar ligaments, inner cuneiform ligaments that are often injury to get the so-called Liz Frank injury. In terms of the Liz Frank complex, look at this foot here. This is a more subtle case of proximal subluxation at the medial cuneiform into the navicular cuneiform joint. You can see how similar in heights the first and second TMT joints are. And that whole medial cuneiform has slid into the medial side of the navicular. And this was dovetails into this injury pattern, which was described by Dr. Porter in 2019. There's the traditional, the medial column dislocation, which is shown here and the proximal extension dislocation. But football and wakeboarding were most commonly associated with the medial column dislocation. So these require a longer return to sports. You can see it, all the cuneiform ligaments there in the inner cuneiform between the medial and the middle have been torn and you get some impaction into the navicular. Here's a surgical parole we had from Harbor a few months ago. And in this case, the navicular didn't break, but the cuneiform did. So you can see a fracture there. If we look at the video here, you can see that the definitely some instability in this area here. You just see that widening and that really some instability in between that area there, just completely unstable all the way back into the navicular. As we look into this area, what we've done is put a couple of K wires in the medial cuneiform and the navicular, and just use some distraction to get that back out to length. You can see it kind of sitting nicely there. So if you need to get some added length, this is a nice thing to use if you don't have the so-called threaded distractors. So we've made kind of our own distractor here for that instability that we see intraoperatively. In terms of the another kind of, this is what we did in that case. We put K wires across it once we reduced it and then did spanning fixation from the navicular all the way into that first metatarsal and through that particular case. This was another case, similar sort of injury pattern, but in this one, you can see the navicular is completely shattered. So instead of spanning across this area, we went ahead and fixed the navicular and the lisfranc area there. And you can see that dorsal plate across the navicular to just help hold things in place with the significant combination that was present. I think we have a better understanding of the high energy lisfranc injuries. This was a level one data from Coetzee in Minnesota from years ago, and he recommended a primary fusion of the first three columns. But again, keep in mind this for high energy lisfrancs. This wasn't necessarily for low energy lisfrancs or the so-called sports lisfrancs. So although it might be a more dramatic initial x-ray and a little bit more operative work, they think they have better outcomes with these fusions for these particular type of patients. The early reduction of these cases is important. So in this particular case, we had a 20 foot fall. And why do we care? We care because it has to do with the energy imported to that foot. And you can see that significant dislocation that's present. So how are we going to treat this one? ORIF with screws or possibly plates, fuse all five rays or fuse just the first two to three rays or potentially an amputation. And I think the best way to go with this would be to fuse the first two to three rays. And that's what we end up doing in this particular case. We fuse the first and second ray. We've fixed the lateral column. As you know, you need more motion there. So we try not to fuse the fourth and fifth rays and we've left the third alone in that particular case. The benefits of the arthrodesis is it's one surgery, not three. You don't have to go back and do a hardware removal and then a fusion. So perhaps a faster return to work and the injury or the biologic milieu might be better for healing in the acute setting. We don't necessarily recommend this for athletes. And this is more level five evidence. But I think a lot of athletes need some motion of their medial column to really restore high level full function. In particular, a patient like this, a 300 pound female, no diabetes, no medicines, no tricks here, just a ground level fall. Would you consider it to be a low energy injury? She was seen within a week of injury, so it wasn't subacute. Would you for this one do an RAF with screws, an RAF with a plate, non-operative or a cast arthrodesis of the first three or first all five? And in this case, this was years ago and beginning of my practice, I fixed it with screws and you can see she really followed directions and was really a great patient. But at three, three and a half months, right when we're ready to take the screws out at four months, she went ahead and broke that screw. And that's a hard screw to get out. You need to make a big hole in that second metatarsal to ream that out. It might leave some problems if you just leave that there. So this kind of piqued my interest about using plates for some of these ORFs because of the problems with screws is that significant displacement you can get from fracturing the screws. So how do we decide fix or fuse? Well, preoperatively, I look at the mechanism of injury, low versus high, and the degree of displacement. Low energy ones, I'm going to try to avoid a fusion. Acute versus subacute are arbitrarily kind of cut that off around six to seven weeks. If it's longer than that, then I'm really leaning toward a fusion. Revision cases, I'm really leaning toward fusions. And again, I look at the age and activity level of the patient. Interoperatively, we're going to look for articular damage or peri-articular comminution. That's going to tilt our hand toward fusing this as well. So in general, you'll fuse the high energy ones and how will you know? You'll know, you'll see the x-rays. Delayed multi-column displacement, regardless of the energy, you're going to fuse. Revision cases, you're going to fuse. And if you get in there and there's significant articular comminution, you'll probably fuse those. I'll fix the stress positive low energy ones and the displaced low energy, especially in young athletes. And the ones we don't fix or fuse, we'll leave alone, are the stress negative ones, which are rare, but happen less than 10% of time, or those medically unfit for surgery. Incisions for fusion, I've kind of been doing more medially lately, and that allows me to place a plantar plate over the first TMT joint, and then a dorsal incision for two and three. It gives me a longer skin bridge between those two plates that I'm using there. You can also do a long extensile, as you saw from that video earlier, and then I'll go laterally for the fourth and fifth if needed. For an ORF low energy, I'm usually making a dorsal incision between EHL and EHB, and the neurovascular bundle is moved laterally. In terms of plates or screws, for fusions, if there's no comminution, I'll use two or 3.5 screws for the first TMT and one for the second and the third. If there is comminution or the patient's larger, I'll use 2.4 to 3.5 bridge plates with supplemental screws for compression. Now, staples are a viable option as well, quicker option, as long as the patient has good dorsal bone stock. For the ORF, I'll use bridge plates almost exclusively. These range in size from 2.4 to 3.5. Not typically do I use a home run screw with that bridge plating. Flexible fixation I'll discuss in detail in a little bit. So fix or fuse, this study came out of San Diego from the Naval Medical Center there. This was low energy, Liz Frank, active duty patients, 32, 14 of which were fused and 18 of which were fixed. The fusion group returned to full duty at 4.5 months, almost two months earlier than the ORF group. But keep in mind that the hardware removal delays the return. They had better fitness scores with the fusion at one year, but no difference in FAM scores at three years. So better early outcome with the arthrodesis, but long-term effect of this is not known. And I'm talking 5, 10, 15 years down the road and equal FAM scores at the long-term three-year mark. Hardware removal, well, if you look at this and you remove that from reoperation rates, when you exclude hardware removal, reoperation rates are very similar between ORF and a primary fusion. So keep that in mind when you're looking at the data. A lot of these, like the last study, say that the reoperation rates are considered a complication. And a lot of times they're not a complication. You're knowing going into that first surgery that you're planning to take that hardware out in anywhere from four to six months. This study was very interesting out of Norway. This was a level one study, fix versus fuse, 24 primary arthrodesis versus 24 bridge plating cases of only the first TMT joint. So they fused the second and third in both groups. I wish they could have just kept some fused and then left the other ones bridge plated or ORF and had a subset of patients who were just fused one, two, and three, and then fixed one, two, and three. But in this particular case, the only joint that was treated differently was the first TMT joint. And they had the same AOF score and pain score, FF36, a two-year follow-up, and a little better alignment in the first TMT joint with the bridge plating as well. But as mentioned, this study I think had some minor drawbacks to it. Flexible fixation, can you do it? Well, there's been a nice study out of Brazil that showed the biomechanics of it, of the sutures, they can achieve similar stability to traditional screws. In terms of a clinical study out of Korea, this was level three, 32 screws versus 31 suture buttons, no difference in scores or pain scores at one year. So it is a possibility. Who and when, why should you do it? Well, why do it? Well, the nice part is no hardware removals needed. When would you do it? I'd recommend it for low energy injury cases. And when, when there's no multi-column involvement. If you're seeing a foot that's completely dislocated, I don't think it's the best option for that. So if it's pure C1M2 diastasis at the Lisfranc joint with a relatively stable first and second TMT joint, I would recommend doing it. And this was a case of a 24-year-old professional surfer that came to see me. And you can see some edema in that MRI, but the x-ray itself doesn't look too bad. Maybe a subtle lateral shift to that second metatarsal, but really a hard cell. So what do we do with this particular patient? Stress view, CT scan, consider flexible fixation, or maybe a plate. So in this particular case, they did that stress view and you can see that mild lateral shift there at the base of the second metatarsal with stress, but overall the first TMT joint looks pretty good. So there's no real instability here at the TMT joint, just at that second. So in this particular case, I used flexible fixation, was able to tighten that down, still with an open approach and still getting a nice reduction, but then using flexible fixation here. And why bother fixing these at all with this nice study out of the UK from last year. And they looked at 26 patients followed for five years and they saw the rate of displacement was 54%. So more than a half of these would displace. The flex sign was not associated with the risk of displacement, but the outcome of fixation was similar to those that remained non-displaced. So look at this, over half of these cases, and we've all seen them in our clinic, have gone on to shift or have a displacement and they just take a long time to get better. So I've been more aggressive with these low energy injuries, even with mild displacement. And then return to sports. This study out of Australia from about three years ago showed 55 year old or younger. So who went over at ORIF for the Liz Frank joint. Now these were recreational athletes, not professional. The typical fixation pattern was seen here. 33 patients had nearly three year follow-up. Hardware removal was scheduled at six months, 94% returned to some sport, but only 66 or two thirds returned to their pre-injury level. And one third had some degree of ongoing pain. So the conclusion from this study was a severe injury with good, but not great outcomes in an athletic population. And this is kind of what you saw there in terms of what they're able to get back. What they classified as impact high or low is a little easier. It looked like to get back to the lower impact. Although, you know, five out of seven went back to surfing, which they considered high impact. And then the last case I'll leave you with, you can see a high energy sort of case we saw from Harbor UCLA. And we did have a distractor in this case. So we distracted it, got it out to length. We temporarily placed K wires across that first TMT joint. And then we went with kind of the medial plate from that approach. Let us make a dorsal incision to pin lesser metatarsals. And then we have a crossing screw there for extra fixation. So there you can see the final fixation in this pretty dramatic Liz Frank injury. So in summary, it's about 0.2% of all fractures. I think that's underestimated. The subtle Liz Franks are becoming increasingly recognized. It can lead to significant disability. We talked a lot about diagnosis and prognosis and keep in mind it's a different animal with the same name and not already created equal. High index of suspicion and they're often missed. So things we've hopefully learned. One, flattening of the arch occurred in 43% of low energy injuries after they were fixed. With careful scrutiny, non-weight-bearing views can show Liz Frank injuries in 90% of cases if you know what to look for. Remember that so-called Liz Frank jut. There's a newer injury pattern out there with proximal migration of the medial ray and know how to fix it. Flexible fixation in my mind is a viable option, but really in those cases where there's pure C1M2 diastasis and 54% of low energy Liz Franks displaced over time. So it might be a good idea to fix it early. Thank you very much.

Liz Frank injuries

prognosis

diagnosis

treatment options

return to sports