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Lisfranc ORIF / Arthrodesis Technique 28615

 

synonyms:Lisfrance arthrosis, Lisfrance fusion, Lisfranc fracture ORIF, tarsometatarsal fusion, tarsometatarsal ORIF, tarsometatarsal arthrodesis

Lisfranc Arthrodesis / ORIF CPT

Lisfranc Arthrodesis / ORIF Indications

  • Acute Displaced Lisfranc fx-dislocation with ligament instability (TMT joint displaced greater than 2mm)
  • Chronic Lisfranc injuries (>6weeks)

Lisfranc Arthrodesis / ORIF Contraindications

  • Soft tissue compromise
  • Inadequate arterial inflow

Lisfranc Arthrodesis / ORIF Alternatives

  • Non-op treatment

Lisfranc Arthrodesis / ORIF Pre-OP Planning

  • K-wire fixation has been shown to often lead to migration of pins, pintract infection, loss of reduction and should not be used except int he 4th and 5th TMT joints.
  • Avoid arthrodesis of the more mobile 4th and 5th tarsometatarsal joints even in the presence of radiographic arthrosis. (Sangeorzan, Foot Ankle 1990;10;193-200).
  • Smoking is prohibited, especially for patients undergoing fusion.
  • Use pre-op xrays of the normal side to plan surgery and bring the to the OR to assess reduction intraoperatively.
  • For patients with chronic injuries/erosions bone graftsmay be needed.
  • Primary arthrodesis is performed as described below, except cartilage and fibrous tissue are resected and the joints are decorticated before fixation. (Ly TV, JBJS 2006;88:514).
  • Lisfranc Case Card.

Lisfranc Arthrodesis / ORIF Technique

  • Sign operative site.
  • Pre-operative antibiotics, +/- regional block.
  • Supine position on radiolucent operating table. All bony prominences well padded. tourniquet high on thigh.
  • General endotracheal anesthesia
  • Examination under anesthesia.
  • Prep and drape in standard sterile fashion.
  • Dorsal incision between 1st and 2nd web space
  • EHL, deep peroneal nerve, DP artery identified and retracted as a unit
  • expose 1st, 2nd, TMT joints
  • Debride hematoma, small, irreducible bone fragments
  • Reduce beginning medially progressing laterally
  • Align medial aspect of 1st MT with medial cuneiform to reduce 1st TMT.  Expose entire medial aspect of 1st TMT joint to ensure no plantar gapping exists
  • Provisional fixation with k-wire, final fixation=3.5/2.7mm coutersunk fully threaded screw from base of 1stMT into medial cuneiform.
  • 2nd MT reduced to medial border of middle cuneiform, k-wire>3.5/2.7mm fully threaded countersunk screw from base of 2ndMT into middle cuneiform.
  • 3.5mm screw from medial cuneiform into base of 2ndMT
  • Dorsal incision between 3rd 4th MT, 3rd TMT joint reduced >k-wire>3.5/2.7mm countersunk screw from base of 3rdMT into lateral cuneiform
  • 4th, 5thTMT joints usually occurs with reduction of first three and is fixed with percutaneous k-wire fixation
  • If pt has associated nutcracker cuboid fracture, must anatomically reduce with distraction bone grafting and plating.  May need intra-op ex fix for distraction. (Sangeorzan JBJS BR 1990;72:376)
  • Navicular fractures fixed with 3.5/2.7mm screws via extended dorsal incisions
  • Irrigate
  • Close in layers.
  • SLC, non-weight bearing

Lisfranc Arthrodesis / ORIF Complications

  • Compartment syndrome
  • Cellulitis / wound infection
  • Contracture (especially if skin grafts are needed to close open wounds)
  • CRPS
  • Vascular injury: dorsalis pedis artery often disrupted (mutiple branches of ant/post tibial A. therfore usually not a problem)
  • Superficial peroneal nerve palsy
  • Post traumatic arthritis (dependent on injury to articular cartilage and failure to achieve an anatomical reduction)
  • Hardware failure / Broken screws
  • DVT/PE
  • Incomplete reduction or redislocation: frequenlty results in permanent disability with chronic pain,
  • Postraumatic deformity (usually planovalgus)with difficulty wearing shoes.
  • Chronic pain
  • Malunion (second tarsometatarsal joint dorsolateral angulation most common).
  • Nonunion

Lisfranc Arthrodesis / ORIF Follow-up care

  • Post-op: Bulky-Jones Posterior splint, NWB, elevation
  • 7-10 Days: Wound check, confirm reduction on xrays. Short-leg cast, NWB
  • 6 Weeks: Remove 4th,5th MT pins at 6-8 weeks. Place in cam-walker / fracture boot. Begin partial weight bearing at 10 weeks.
  • 3 Months: Review xrays. Wean out of cam-walker.
  • 6 Months: Fit custom-molded semirigid orthotic with arch support. Progress with activities.
  • 1Yr: Assess outcomes. Follow-up xrays. Symptomatic screws may be removed after 16wks
  • Outcome measures: AOFAS midfoot score.

Lisfranc Arthrodesis / ORIF Outcomes

  • (Myerson, Foot ankle 1986;6:225)
  • CR casting = 20% good/excellent results
  • CRPP = 53% good/excellent
  • ORPP= 78% good/excellent
  • ORIF=93% good/excellent in closed injuries worse for open injury (Arntz, JBJS AM 1988;70:173)
  • Early restoration of joint congruity has improved outcomes over nonanatomic treatments. Brunet JA, Wiley JJ: The late results of tarsometatarsal joint injuries.  J Bone Joint Surg 1987;69B:437-440.
  • (Arntz CT, JBJS 1988;70A:173).
  • Outcome measures: AOFAS midfoot score.

Lisfranc Arthrodesis / ORIF Review References

  • Sangeorzan BJ, in Masters Techniques in Orthopaedic Surgery: The Foot and Ankle, 2nd Ed, Lippincott, 2002
  • Rockwood and Green's Fractures in Adults 6th ed, 2006
  • Ly TV, Coetzee JC. 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 Mar;88(3):514-20.
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