Hello, everyone, my name is Kelly Hines from the University of Chicago Medicine. I'm here to present you this on-demand lecture regarding Lisfranc injuries, the latest in fixation techniques. Here are my disclosures and non-conflict with this presentation. So my goal today is to review the most current concepts around the treatment of Lisfranc injuries and an update on fixation techniques available and how you might choose between the options for techniques. And then I'll review a case-based strategies for the treatment of complex cases. So on presentation, patients with Lisfranc injuries, there's some important concepts and really key physical examination points to remember. We really wanna understand the patient's mechanism of injury. Often athletes who suffer Lisfranc injuries have an indirect mechanism like an axial load to a plantar flex foot. And patients who suffer a higher energy trauma may be at risk of suffering these injuries. Plantar ecchymosis is often considered a hallmark of the physical exam for a midfoot fracture dislocation. And patients often struggle with weight bearing due to pain after this type of injury. On physical exam also, there's typically swelling over the midfoot. And regarding imaging, it's really important to consider the imaging and what's been done given that many Lisfranc injuries are misdiagnosed or undiagnosed at initial presentation. If initial non-weight bearing x-rays do not reveal the injury or correlate with the clinical exam in history, weight bearing exercises can be a very important adjunct. These x-rays on the left are monopodial weight bearing AP x-rays that show Lisfranc injury on the right side compared to the normal alignment on the left. You may consider abduction and adduction stress views. These are variably done with or without anesthesia, but it can be helpful in delineating an unstable injury. CT scan can show the degree of combination of identified fractures, but also identify additional fractures of the metatarsals and tarsal bones. MRI may be useful if we have high clinical concern for a Lisfranc injury, but it's not apparent on other imaging modalities. And if the plantar ligament is found to be intact on an MRI, it is found to be highly sensitive for identifying a stable foot. Lisfranc injuries have a large spectrum of injuries. They go from low energy athletic injuries all the way up to complex high energy injuries with soft tissue compromise. These can range from purely ligamentous injuries all the way up to severe fracture dislocation injuries with soft tissue coverage needs. About 43% of Lisfranc injuries occur after a motor vehicle accident with about 24% resulting from a fall from height, 13% being crush injuries and 10% sports injuries. And there are several principles to consider when treating patients with Lisfranc injuries. First of all, you need to identify the injury and the instability, understanding what is occurring prior to operating. An anatomic reduction is the key. It's not all about what fixation is used. This is really the key to as much success as possible. Open reduction is necessary. Closed reduction is found to result in a higher rate of malreduction and rigid fixation is required. K-wire fixation alone is typically not sufficient for maintaining the reduction during healing. And despite all of this and following these principles, some of these patients will still suffer from post-traumatic arthritis. And above all, respect the soft tissues, especially in high energy Lisfranc injuries. It's not impossible to perform definitive treatment immediately. You may have to await swelling reduction prior to surgery. And a note on a proximal variant Lisfranc injury, this is one that extends approximately through the first intercanaeoform joint, exiting the medial navicular canaeoform joint. Fixation techniques have been debated and have resulted in many controversies over the years. One of the main controversies is fixing versus fusing, whether to use transarticular screws or dorsal bridge plating, when and how to use K-wire fixation, do suture buttons have a role in fixation, and then should we remove the hardware? First of all, the controversy around fix versus fusing. This is still controversial and there are some disagreements in the literature. Kudsia et al in 2006 presented a prospective study which resulted in better outcomes for patients who were fused in all ligamentous injuries. There are some common practices in terms of when to fuse in a Lisfranc injury though, and that may be if there's significant articular damage, a delayed presentation, especially beyond six weeks from injury. The obese or elderly may be better served with fusion. And the one scenario where fixing does have a better effect and a disadvantage is that there does require more repeat operations for hardware removal with fixing. If there is general consensus though, to continue to fix high-level athletes to maintain the flexibility of the foot where possible. Transarticular screws are commonly used now for non-essential joints in the medial and middle column, such as the home run screw from the medial cuneiform to the base of the second metatarsal, or between the first and second cuneiforms. There is some debate as to whether to use solid versus cannulated screws, although solid screws are more commonly used in a review of the literature. There is also some debate as to whether to perform these screws using lag or compression techniques. However, the advice is to avoid over-compression of this joint, which may lead to malreduction. The home run screw can be placed anti-grade or retrograde. There is no consensus as to which is better or more effective, and this is still up to surgeon preference. Bridge plating has become popular, especially for the tarsometatarsal joints, which are considered more essential joints, having more motion at baseline. There has been a study looking at the amount of articular damage using transarticular screws, which is about two to 6% of the articular surface. There's really been no difference in functional outcomes looking at bridge plating versus transarticular screws, and really no differences in stability or strength of fixation. One scenario where it can be very helpful to consider bridge plating is when there's comminuted base fractures of the second and first metatarsals, where it may be challenging to achieve strong fixation with transarticular screws alone. That's the example here using an H-plate due to the severe comminution of the base of the second metatarsal. The lateral column has traditionally been treated with K-wire fixation due to the increased mobility of the lateral column relative to the medial column, and this is temporary fixation. There are some debate as to whether lateral column fixation is required at all if it appears stable after the fixation of the medial column, and there seems to be a trend in the literature towards less lateral column fixation overall. Suture button fixation is being looked at with some studies in the literature that are still quite small. There is a study looking at a small number of high-level dancers where suture button fixation was used effectively with the goal of preserving motion, although the research is still very limited, and we are not yet at a point where we can say that this is viable treatment for Lisfranc injuries, especially without long-term results. This is my one patient who did have a suture button fixation of Lisfranc injury by another provider who presented to me with symptomatic arthrosis of the second tarsometatarsal joint, went on to fusion. And then there are the higher energy injuries that require more soft tissue management, potentially closed reduction, or even a staged approach with two trips to the operating room. The patient is very unstable in terms of the Lisfranc injury. They may need a closed reduction and possibly many open with percutaneous pitting in order to stabilize the foot in preparation for definitive fixation at a later date. And an external fixator is also a useful adjunct in treatment of these very high energy injuries that are not able to be stabilized in any other way. A few cases to review scenarios where a staged approach may be helpful. This is a 70-year-old lady who suffered this foot injury in a high-speed motor vehicle accident and also had multiple other orthopedic injuries. You can see her first metatarsal is in communication with her middle cuneiform rather than the medial cuneiform, a significant displacement on the lateral view as well. She actually went to the operating room within a day of presentation for closed reduction and percutaneous pitting to get her foot closer to anatomically aligned and allow for soft tissue rest. We returned to the operating room with her two weeks later for definitive treatment with fusion of the first, second, and third tarsal and metatarsal joints as well as intra-cuneiform fixation. The second case here is a 13-year-old girl who suffered the severe foot, soft tissue, and bony injury in an ATV rollover. She underwent emergent irrigation and debridement with open reduction given her soft tissue exposure. You can see on these splinted x-rays, not much, however, you can see that the first metatarsal and medial cuneiform are divergent medially compared to the rest of the midfoot. We performed K-wire fixation at the time of initial irrigation and debridement as this was a very severe open and contaminated wound. Given her age being 13 and the severity of her soft tissue injuries, this ended up being her definitive fixation and the wires were pulled at 12 weeks. She maintained her reduction. She had free flap coverage for the soft tissue on her foot. This third case is a 49-year-old man who was involved in a motor vehicle accident, motorcycle accident actually, and suffered multiple traumatic injuries, including this foot injury. His foot was extremely swollen at the time of presentation and he was undergoing other damage control orthopedic treatment at this time. For his initial treatment, we performed closed reduction with percutaneous pinning of the medial column and then a lateral column external fixator to maintain the length of his lateral column. His soft tissues were not ready for definitive fixation for a very long time as the lateral column injury was an open injury with significant dorsolateral wound, which was managed by plastic surgery without flap coverage. He ended up with a delayed medial column fusion after about eight weeks from his initial injury due to his wound, as well as other injuries. His lateral column was non-reconstructible at that time due to significant soft tissue compromise and the fact that he was not considered a flap candidate due to his smoking status and other chronic medical issues. He actually does have a plantigrade foot and is weight bearing and getting back to his activities quite well. So in summary, I just wanted to really highlight that these Lisfranc injuries represent a major variety of injuries and now we have multiple options for fixation. I think it's very important to consider all patient and injury factors in selecting the fixation for a Lisfranc injury and there's not any one right answer. The real answer is that anatomic reduction is key and respecting the alignment of the midfoot is the reason we treat these injuries operatively to begin with. Thank you so much.

Lisfranc injuries

fixation techniques

diagnosing Lisfranc injuries

imaging modalities

treatment principles