Lisfranc Injuries in the Athlete PDF

LISFRANC INJURIES Ashley M. Dikis, DPM, FACFAS Assistant Professor Des Moines University College of Podiatric Medicine & Surgery Objectives ▪ Recognize key tarsometatarsal anatomical landmarks. ▪ Identify radiographic findings associated with Lisfranc injuries. ▪ Recognize various treatment opt...

LISFRANC INJURIES Ashley M. Dikis, DPM, FACFAS Assistant Professor Des Moines University College of Podiatric Medicine & Surgery Objectives ▪ Recognize key tarsometatarsal anatomical landmarks. ▪ Identify radiographic findings associated with Lisfranc injuries. ▪ Recognize various treatment options for Lisfranc injuries and their benefits. 2 Outline 1. Introduction 2. History 3. Anatomy Review 4. Mechanism of Injury 5. Classifications 6. Physical Exam 7. Imaging 8. Management 3 Introduction 1 Introduction ▪ Injury involving the tarsometatarsal joints ▪ Spectrum of injury ▫ Ranges from sprain to fracture-dislocation 5 Introduction Relatively uncommon in general population (0.2%) 2nd MC in athletes 4% of football players Can lead to long-term morbidity if not appropriately and promptly treated 6 History 2 ▪Jacques Lisfranc de St. Martin ▪1787-1847 French surgeon in the Napoleonic wars Described amputation at the level of the tarsometatarsal joint Soldiers fall from horse, foot in stirrup 8 History Quenu and Kuss (1909) Original classification Hardcastle (1982) Further classified based on displacement and incongruity Myerson (1999) Direction of dislocation 9 Anatomy Review 3 11  Intrinsic stability provided by arch Second metatarsal keystone Intermetatarsal ligaments Lisfranc ligament: medial cuneiform to base of second metatarsal 12 13 Mechanism of Injury 4 MOI High energy incidents (ex. MVA) Low energy (missed step, sports) Aitken and Poulson (1963) Direct Indirect 15 MOI Direct Crush Often with dislocation Soft tissue compromise Indirect Axial force applied to a plantarflexed and inverted foot with an additional rotational force 16 Classifications 5 Quenu & Kuss Hardcastle Isolated Homolateral Divergent 18 Myerson 19 Nunley & Vertullo Low energy injuries 1. Low-grade sprain with dorsal capsular tear (normal xray, + bone scan) 2. Elongation or disruption of Lisfranc ligament complex, intact plantar capsular structures (xrays with 1-5mm diastasis between M1-M2 on AP WB xray) 1. Non-Operative care 3. Disruption of dorsal Lisfranc and plantar ligament, greater than 5mm diastasis and loss 2. Debate; Operative of arch height on lateral WB xray 3. Operative Care 20 Physical Exam 6 Physical Exam ▪ When did it happen? ▫ Diagnosis within 6 wks ▪ Typically complain of diffuse pain ▪ As with most foot and ankle trauma, compartment syndrome must be a consideration 22 Physical Plantar ecchymosis Mondor’s sign Piano key Pain on palpation Soft tissue envelope “Tenting” – pressure necrosis Rarely open injuries Often with significant edema 23 Imaging 7 Imaging X-ray “Plain film” AP: Diastasis between 1st and 2nd Lateral displacement of second on intermediate cuneiform Disruption of first TMT “Fleck” fragment Lateral: “Step off”—dorsal met and cuneiform should be aligned 25 Imaging 26 Imaging Stress abduction x-ray High suspicion with neg x-ray Painful; typically requires anesthesia Immobilize hindfoot and apply passive pronation and abduction 27 Imaging Beware “Foot sprain” NWB x-rays in ED, urgent care, hospital, PCP Anatomic variants Contralateral weightbearing AP can be helpful in diagnosis of subtle injuries Os intermetatarsum 28 29 Imaging CT Most useful in high energy injuries Unimpeded view of osseous structures Up to 50% more metatarsal and tarsal fractures visualized Intraarticular involvement 30 Imaging ▪ MRI ▫ Most useful in low-energy injuries ▫ Superior visualization of soft tissue ▫ Three separate bands ▫ Can also visualize capsular and other intermetatarsal and intertarsal ligament injuries 31 H Mulcahy. Lisfranc Injury Current Concepts. Radiol Clin N Am 2018; 56: 859-876 32 Management 8 🔨 Non-Operative ▪ Reserved for sprains and patients who are not stable for surgery ▪ High rates of complication if not stabilized appropriately 34 🔨 Operative Closed reduction and percutaneous fixation or casting ORIF Primary arthrodesis In general, presence of incomplete versus complete ligament disruption is helpful in guiding treatment 35 🔨 Operative ▪ Closed reduction ▫ Performed in OR ▫ K-wires or external fixation ▫ Not commonly utilized as primary treatment ▫ May be used temporarily if severe soft tissue damage present 36 🔨 Operative Incisional approach One versus two incision Dependent on lateral involvement and surgeon preference 37 🔨 Operative ▪ ORIF ▫ Reduction of deformity ▫ Often requires transarticular fixation ▫ If comminution present but ORIF still attempted, dorsal bridge plating utilized ▫ Percutaneous pinning of 4th/5th TMT ▫ Plan to remove hardware from 3-6 months post-operatively 38  Sigvard Hansen. Functional Reconstruction of the Foot and Ankle. 2000. 🔨 Operative Primary arthrodesis Involved joints are generally deemed nonessential First, second and third TMTJ Reported rates of post-traumatic arthritis following ORIF for Lisfranc dislocation is 40-90% 39 🔨 Operative Primary arthrodesis Ly & Coetzee (2006) Prospective study Improved outcomes in patients following arthrodesis versus ORIF, particularly with complete ligamentous disruption Reoperation rate of ~75% in ORIF versus ~20% following arthrodesis 40 🔨 Operative Low energy more common in athletes and therefore more often missed Return to sport NFL: ~ 90% Soccer: ~94% Trend towards decreased performance in sports that require cutting-movements and high impact 41 🔨 2023 ▪ Isolated second TMTJ Lisfranc injuries ▫ ORIF with screw or flexible fixation is a reasonable option ▪ Fractures, intra-articular comminution, or multiple levels of joint injury ▫ Primary arthrodesis may allow an earlier return to activity, work, and sport. 42 🔨 43 🔨 2023 44 🔨 Operative Return to sport Operative management recommended Some studies recommending hybrid approach (flexible and traditional fixation), though research to support is lacking Return to sport time varies depending on severity and procedure 45 SUMMARY No one way to treat all Lisfranc injuries Variation in severity and pattern High suspicion and early detection High rates of DJD and long-term sequalae Perc fixation vs ORIF vs primary arthrodesis Patient education 46  References 1. McGlamry’s Comprehensive Textbook of Foot and Ankle Surgery. Volume 2, Chapter 106. 2. Aiken & Poulson. Dislocations of the Tarsometatarsal Joint. JBJS 1963; 45-A(2): 246-260. 3. Mulcahy H. Lisfranc Injury Current Concepts. Radiol Clin N Am 2018; 56: 859-876. 4. Coetzee C. Making Sense of Lisfranc Injuries. Foot Ankle Clin N Am 2008; 13: 695-704. 5. Ly & Coetzee. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am 2006; 88(3): 514-520. 6. AO Foundation Surgery Reference. 7. Hansen S. Functional Reconstruction of the Foot and Ankle 2000. 8. Lewis & Anderson. Lisfranc Injuries in the Athlete. FAI 2016; 37(12): 1374-1380. 9. Hardcastle et al. Injuries to the tarsometatarsal joint: incidence, classification and treatment. J Bone Joint Surg Br. 1982; 64: 349–356. 10. Myerson MS. The diagnosis and treatment of injury to the tarsometatarsal joint complex. J Bone Joint Surg Br. 1999; 81: 756–763. 11. Myerson MS et al. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986; 6: 225–242. 12. Quenu E, Kuss GE. Etude sur les luxations du metatarse (Luxations metatarso-tarsiennes). Du diastasis entre le 1er et le 2e metatarsien. Rev Chir. 1909;39:1–72. 13. Nunley & Vertullo. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med 2002; 30(6): 871-878. 14. Ma & Jennings. Lisfranc Injuries in the Athlete. Clin Pod Med Surg 2023; 40: 39-54. 15. Hofbauer et al. Lisfranc Injuries. Clin Pod Med Surg 2024. https://doi.org/10.1016 /j.cpm.2024.01.014. 47 Thanks! Any questions? Copyright Notice: This presentation may contain copyrighted material used for educational purposes under the guidelines of Fair Use and the TEACH Act. It is intended only for use by students enrolled in this course. Reproduction or distribution is prohibited. Unauthorized use is a violation of the DMU Integrity Code and may also violate federal copyright protection laws. 48 Credits Special thanks to all the people who made and released these awesome resources for free: ▪ Presentation template by SlidesCarnival ▪ Photographs by Unsplash 49