Lisfranc Injuries

Keith D. Cook, DPM Director, Podiatric Medical Education University Hospital Newark, New Jersey

JULY 13, 2019 Disclosures

DePuy Synthes: Consultant, Lecturer Osteomed: Consultant, Lecturer, Royalties

UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 2 Objectives

Maintain a high clinical suspicion for Lisfranc fracture-dislocations

Decide between Open Reduction Internal Fixation versus Primary Arthrodesis

Utilize latest fixation techniques

UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 3 Lisfranc Fracture-Dislocation

Overall frequency: • Lisfranc = 14% of all foot and ankle injuries • 20% Misdiagnosed

4 Obvious Subtle

5 Clinical Suspicion Edema Ecchymosis Erythema Pain Unable to walk Fracture blisters Compartment syndrome?

6 Diagnosis

X-rays Contralateral x-rays Stress radiographs CT Scan MRI for ligament rupture

7 “Outcome After Open Reduction & Internal Fixation of Lisfranc Joint Injuries” Kuo, Hansen, et al. JBJS 82-A(11), Nov. 2000

Review of 48 patients with Lisfranc ORIF

Pts. with non-anatomic reduction had a significantly higher prevalence of post- traumatic osteoarthritis than did those with anatomic reduction

Anatomic reduction resulted in better AOFAS & MFA scores

“Anatomic reduction & stable internal fixation has become a standard principle governing treatment of tarsometatarsal fracture-dislocations”

8 Treatment

“It is well accepted that patients are likely to develop late joint deformity at the tarsometatarsal junction, joint separation, and radiographic and clinical evidence of post- traumatic arthritis when anatomic reduction is not obtained.” • Teng, Pinzur, et al. Foot ankle Int. 23:922-926, 2002.

9 Treatment

Fusion vs ORIF

3.5 or 4.0mm screws K-wires Ex-Fix Bridge Plating

10 “Treatment of Primary Ligamentous Lisfranc Joint Injuries: Primary Arthrodesis Compared with Open Reduction and Internal Fixation” Ly, Coetzee. JBJS 88-A (3) March 2006

20 pts. w/ ORIF, 21pts. w/ primary arthrodesis 2 years post-op AOFAS score: – ORIF = 86.6 – Arthrodesis = 88 5 ORIF pts went on to arthrodesis Post-injury activity level: – ORIF= 65% – Arthrodesis = 92%

11 “Arthrodesis vs ORIF for Lisfranc Fractures” Sheibani-Rad S, Coetzee JC, et al Orthopedics 2012

Systematic Review 6 articles

Fisher’s exact test revealed no significant effect of treatment group on the AOFAS score percentage on patients who had an anatomic reduction

This study highlights that both procedures yield satisfactory and equivalent results

12 “Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis.”

Clinical Orthopedics & Related Research, 2016

3 studies

Risk of hardware removal higher for ORIF group

No risk difference for revisional surgeries or non-anatomic reduction between groups

Patient recorded outcomes did not favor either group

13 A Systematic Review and Meta-analysis of the Treatment of Acute Lisfranc Injuries: Open Reduction and Internal Fixation versus Primary Arthrodesis Foot Ankle Surgery, April 2019 8 studies (2 RCT, 6 non-RCT studies)

547 patients

No statistically significant difference between ORIF versus PA in return to work or activity and satisfaction rates

ORIF group higher risk of hardware removal

Overall complication rates equivalent in both groups

UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 14 Reoperation Rate Differences Between Open Reduction Internal Fixation and Primary Arthrodesis of Lisfranc Injuries Buda, et al. Foot Ankle Int, September 2018

217 patients ORIF = 163, PA = 54

Mean f/u = 62.5 months

Excluding planned hardware removal, reoperation rate: ORIF = 29.5%, PA = 29.6% p = 1

Highest rate for return to OR included deep infection, delayed wound healing and high-energy trauma

UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 15 Cost Comparison and Complication Rate of Lisfranc Injuries Treated with Open Reduction Internal Fixation versus Primary Arthrodesis Barnds, et al. Injury, December 2018

Review of national insurance database of 23.5 million orthopedic patients 2130 patients Non-operative = 1248, ORIF = 670, PA = 212 Average Cost PA = $5,005.82, ORIF = $3,691.97, p=0.045 Complication Rate PA = 30.2% (64/212), ORIF = 23.1% (155/670) Hardware Removal Rate PA = 18.4% (39/212), ORIF = 43.6% (292/670)

Primary arthrodesis is both more expensive and has a higher complication rate than ORIF

UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 16 Lisfranc Screw Orientation?

17 “Determining the Strongest Orientation for “Lisfrancs Screw” in Transverse Plane Tarsometatarsal Injurues: A Cadaveric Study” Cook, KD, Jeffries LC, O’Connor JP, Svach D JFAS. 48(4): 427-431, 2009.

Purpose: To determine the strongest orientation of Lisfranc’s screw when performing ORIF of Lisfranc fracture-dislocation injuries.

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Alternative Lisfranc’s Screw: A Cadaver Study

6 pairs of fresh-frozen human cadavers

2 screw orientations of 3.5mm cannulated partially threaded screws, AO technique

Alternative screw: placed from 2nd met base to medial cuneiform

Tradition screw: placed from medial cuneiform to 2nd met base

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Alternative Lisfranc’s Screw: A Cadaver Study

Pulled to failure with MTS

Results: • Alternative screw mean force to failure=165.1 + 58.6N • Traditional screw mean force to failure=149.0 + 54.9N • p=0.247

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Alternative Lisfranc’s Screw: A Cadaver Study

Conclusion: The Lisfranc’s screw from the 2nd metatarsal to the medial cuneiform provides stability to the tarsometatarsal joint complex equal to or stronger than the traditional orientation.

Technically easier

Orientation of the “Lisfranc Screw” J Orthop Trauma 2012, Vinod K. Panchbhavi, MD

21 KJ

22 23 Morbidly obese F, s/p MVA

24 25 5 months post-op

26 27 26 yo M s/p forklift injury no pmh

28 29 30 2 months post-op

31 Summary

High degree of clinical suspicion

ORIF as effective or more effective than PA with less cost

Alternative fixation techniques

UMDNJ OFFICE OF ADVANCEMENT AND COMMUNICATIONS 32 Thank you!

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