Lecture 44 shah delayed lisfranc
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Transcript of Lecture 44 shah delayed lisfranc
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• Young adult with polytrauma
• Ipsilateral fracture dislocation hip
• Ipsilateral comminuted fracture upper end tibia
• Open Fracture contralateral tibia
• WITH….
In most advanced trauma centre…
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Missed lisfranc: now what?
Dr Rajiv Shah‘Foot & Ankle orthopaedics’
Foot & Ankle SurgeonPresident, Indian Foot & Ankle Society
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Missed Lisfranc
• Lisfranc injury is missed more often that not!
• Reconstruction beyond three weeks usually not done
• Missed lisfranc lands up in to post traumatic midfoot arthrosis
• Should be treated with midfoot fusion
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Midfoot arthritis:
Chronic foot pain
Functional disability
Guidelines lacking
To rigid on push off
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Midfoot Arthritis: Diagnosis
• Pain• Tenderness• Deformity
– Loss of Arch– Midfoot Abduction
• Gait Abnormality– Non Rigid Arch During
Push-Off
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Physical Exam
• N/V status
• Skin condition
• Palpate joints
• Assess alignment– Pes planus– Abduction
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Physical Exam
• Painful motion?
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Radiology
• X-Rays– AP,Lateral, & 30o Oblique
• Parallel to TMT Joint Surfaces– 15-20o Cephalad
– Weight-Bearing
• CT Scan
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Radiology Findings
• X-rays:
• Joint space narrowing
• Osteophytes
• Subchondral sclerosis & cysts
• CT scan:
• Axial and 30° Semi--‐Coronal Cuts
• Articular Incongruity
• Bone Exostoses
• MRI:
• Osteochondral Lesions
• Osteomyelitis
• Extent of Talar Avascular Necrosis
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Diagnostic or Therapeutic Injections
•25-33% accuracy with palpation alone•Must use Fluoro or US
•Extravasation of dye in approx. 20%
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Aims of treatment:
Pain relief by enhancing stability
Fusion in functional position
Plantigrade foot
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Non-Op Treatment
• NSAID
• Activity Modification
• Local steroids
• Stiff soled shoes
• Rocker soled shoes
• Full length steel shank
• Orthotics: UCBL, hinged AFO
• Carbon footplates
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Non-op treatment
• Carbon footplate
Carbon Footplate 70% pain reduction
Steel shank shoe
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Conservative mx:
Carbon foot plate
3Q insert
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Operative Principles
• Fuse only what is painful– Most likely the medial
column• 1st TMT, Navicular-
medial cuneiform
• 2nd TMT and N-MC joints
• +/- 3rd joints
– Don’t fuse 4, 5 TMT• Peroneus tertius
• Resect if necessary but this is rare
• Don’t forget Gastroc
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Operative Principles
• Lazy “C” incision– If going laterally then second incision– FULL thickness flaps
• Denude Cartilage– Untoothed Laminar Spreader– Drill with K-wire to promote healing
• Build the fusion from the medial side to the lateral aspect
• Hintermann retractor
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Operative Principles
• K-wire for temporary fixation– Use crossed screws, dorsal plates
compression staples dorsal locking plate
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• Stability of the fusion can be improved by plates
Tarso MT Joint
Midfoot Joints
Plating allows for reliable fusionCan Hold corrected deformity
Midfoot plusTM Joints
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Dorsiflexion of toes while tightening screws reduces GAP in the joints
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Operative Principles
• Mini Fluoroscopy decreases radiation exposure
• Full thickness closure with nylon sutures– Leave in for 3 weeks; elevate foot
• Well padded splint/cast for 8 weeks NWB
• Walking cast for 4 more weeks
• Xrays at 8 and 12 weeks
• Additional f/u 18 weeks
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Case Example
• Female aged 33 years
• Pain, swelling & inability to ambulate
• 4.5 months post trauma
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Original X-ray
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At surgery….
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Case example:
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Case example:
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Case example:
1st-3rd TMT fusion Isolated 2nd fusion
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Pearls• Don’t do this until the
patient begs you for it…– Outcomes 50-80%
good…not great
• Complications: Non-union, wound problems, infection, nerve injury, continued pain, prominent hardware
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That’s all…
Thank you all..