Lisfranc injuries account for 0.2% of bony injuries.1 The Lisfranc complex includes the tarsometatarsal (TMT) joints and the intercuneiform joints. Variant patterns include concomitant involvement of the naviculocuneiform joint, any of the 5 metatarsals, and the cuboid.2 High-energy mechanisms such as motor vehicle collisions, falls, and crush injuries can cause injury to one or several of the components of the complex. Instability of the Lisfranc complex is readily diagnosed in high-energy injuries secondary to foot deformity, significant swelling, and/or open fractures. X-rays typically show significant displacement or dislocation of the TMT joint complex as well as possible involvement of the metatarsals and/or cuboid.
Biomechanically, the bony contact afforded by the first through the third TMT joints stabilizes the arch during stance and push-off, whereas the fourth and fifth TMT joints are mobile to accommodate terrain.3 The configuration of the mid-foot, with the recessed second TMT joint, limits significant motion within the medial and middle column, which contributes to coronal plane stability. Moreover, it has been shown that even the slightest displacement within the second TMT joint can decrease articular contact area by 25% and destabilize the Lisfranc complex.4
Treatment has focused on obtaining an anatomical reduction of the mid-foot for optimum results.5 Both open reduction and internal fixation and primary arthrodesis have demonstrated good results with maintenance of mid-foot stability and return to function.6,7
The accompanying video (see Video, Supplemental Digital Content 1, http://links.lww.com/JOT/A394) demonstrates the technique of open reduction and internal fixation of a high-energy Lisfranc complex fracture dislocation.
The patient is a healthy 45-year-old man who sustained an isolated injury to his right foot following a motor vehicle collision. Injury radiographs demonstrate dislocation of the first through third TMT joints, subluxation of fourth and fifth TMT joints, dislocation between the medial and middle cuneiform, and third and fourth metatarsal neck fractures. The patient underwent successful closed reduction and splinting in the emergency department. He was taken to the operating room once soft tissues have stabilized and swelling diminished.
The patient was positioned supine on a radiolucent table with a small bump under the ipsilateral hip. The right leg was positioned over a medium triangle to allow for reproducible imagining of the foot. A tourniquet is placed on the ipsilateral thigh, and the C-arm is brought in from the opposite side of the table. A dual-incision technique was performed with the medial incision centered just medial to the extensor hallicus longus and the lateral incision centered over the third metatarsal.
The medial incision was made first, and dissection was carried medial to the extensor hallicus longus paying careful attention not to open the tendon sheath. In most instances, the capsule of the first TMT joint is disrupted, as is in this case, and dissection then proceeds dorsally and plantarly over the joint. The fracture hematoma is evacuated. The neurovascular bundle is identified just medial to the first TMT joint and protected. The lateral incision is made, and dissection is carried to the fascia covering the extensor tendons. The fascia is incised, and the tendons are retracted medially exposing the second and third TMT joints.
The author's preferred technique is to start medially and proceed laterally as the reduction and fixation of the first TMT joint helps to indirectly align the remainder of the mid-foot. The cuneiform is reduced first with a pointed reduction clamp using both cortical and articular landmarks for reduction. A provisional K-wire is used to hold reduction. The first TMT joint is now reduced with a reduction clamp paying attention to the reduction at the plantar surface. Once confirmed, a K-wire is used for provisional stabilization. In this case, the second TMT joint was visualized from the medial incision secondary to the traumatic soft-tissue disruption. Reduction of the second metatarsal is confirmed at the articular margin against the middle and medial cuneiform. The third TMT joint is reduced and provisionally held in similar fashion.
The sequence of fixation follows the sequence of reduction. The middle and medial cuneiform is stabilized by a small fragment cortical screw and verified by fluoroscopy. It is important to place this screw outside the projected path of the antegrade and retrograde cortical screws that stabilize the first TMT joint. The author's preference is to use a 3.5 mm retrograde screw and a 2.7 mm antegrade screw to fixate the first TMT joint. Fluoroscopy is used during drilling to verify appropriate screw trajectory.
From the lateral incision, the second TMT joint is stabilized by a retrograde 2.7 mm screw in similar fashion. In this case, a “Lisfranc screw” is placed from the medial cuneiform to the base of the second metatarsal for added stability. Fluoroscopy is used to verify appropriate trajectory and depth before placement of the small fragment screw. The third TMT is fixated in similar fashion.
The fourth and fifth TMT joints are indirectly reduced by anatomical reduction of the medial and middle columns of the mid-foot. These are stabilized percutaneously. A 0.062 inch K-wire is introduced from the base of the fifth metatarsal into the cuboid. A similar K-wire technique can be used for the fourth metatarsal; however, in this case, the patient had third and fourth metatarsal neck fractures. These were stabilized by 0.062 inch intramedullary K-wires. The fourth metatarsal K-wire was taken into the cuboid to also stabilize the fourth TMT joint. The wire ends are cut and protected using protective caps. X-rays are taken to demonstrate anatomical alignment of mid-foot. The wounds are irrigated and closed using absorbable interrupted sutures subcutaneously and Nylon sutures for the skin. Sterile dressings are applied, and a short-leg posterior splint is placed.
The patient remains in the splint until follow-up at 2 weeks for suture removal. The patient is instructed to remain non–weight-bearing for total of 12 weeks. The pins are pulled at 6–8 weeks postoperatively. Therapy is recommended to the patient once weight bearing has started to work on conditioning and strengthening of the operative extremity. If hardware becomes symptomatic, they can usually be taken out at 9 months to a year after surgery.
The author thanks Roger Huff for filming the video.
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