Surgical Technique

Early injury detection, joint inspection, stable fixation aid Lisfranc ORIF in athletes

Andrew R. Hsu
Andrew R. Hsu

Lisfranc injuries encompass any bony or ligamentous damage that involves the tarsometatarsal joints. Traditionally, these injuries are thought to occur during axial loading of a fixed, plantar-flexed foot, but athletes can often have noncontact twisting injuries that cause Lisfranc disruption. This is particularly true in soccer and American football, where athletes plant their cleats in the ground and pivot around a fixed point in the midfoot. Lisfranc injuries are the second most common foot injury among collegiate football players, and it is estimated that up to 20% of Lisfranc injuries are missed, particularly in the purely ligamentous variants found in athletes and lower-energy injury situations. Clinically, patients often report painful weight-bearing, inability to perform a single-limb heel rise, plantar ecchymosis, and swelling and point tenderness across the bases of the first and second metatarsals.

In athletes, proximal-medial column Lisfranc variants are a common injury that need to be recognized and appropriately managed early. In these injuries, the force imparted to the foot disrupts the Lisfranc joint, extends proximally through the intercuneiform joint and exits out the naviculo-medial cuneiform joint, which causes instability at multiple joints and an unstable first ray. Radiographs are often negative, but stress views can show widening at the intercuneiform or naviculo-medial cuneiform joints. MRI of the foot often reveals edema at the naviculo-medial cuneiform joint. Unrecognized or untreated instability can lead to chronic pain, disability and deterioration of the naviculo-medial cuneiform joint.

One of the clinical decision-making difficulties with Lisfranc injuries is there are no exact diastasis parameters to guide surgery. Patients should be treated based on symptoms, functional needs and degree of instability. It has been shown that patients with up to 5 mm of displacement can still have good long-term clinical results, in select cases, without surgery. Nonoperative treatment is indicated in cases without instability or displacement and this involves protected weight-bearing in a tall controlled-ankle motion (CAM) boot for 4 weeks followed by a progressive increase in activities with return to play (RTP) typically at 6 weeks to 8 weeks after injury.

The goal of surgical intervention is to obtain and maintain anatomic reduction of all unstable midfoot joints in order to restore normal foot mechanics. To obtain a successful outcome, it is important during surgery to remove all interposed soft tissue debris from the Lisfranc joint and directly assess the articular surfaces before placing solid screws and/or plates.

Surgical technique work-up

 a non-contact twisting injury to the foot
Standing AP radiograph of a 33-year-old female soccer player after a non-contact twisting injury to the foot on artificial turf shows diastasis between the bases of the first and second metatarsals with a positive “fleck” sign indicated by the red arrow (a). Coronal MRI shows plantar edema and disruption of the Lisfranc ligament ( red arrow) (b). Sagittal MRI demonstrates proximal edema extending to the naviculo-medial cuneiform joint (red arrow) (c). Ligamentous stability before (d) and after (e) pronation and adduction stress testing of the midfoot under live fluoroscopy shows Lisfranc and intercuneiform instability (red arrows).

Images: Hsu AR

Prior to surgery, it is important to perform a thorough history and physical exam to determine the exact nature of the Lisfranc injury and all the unstable joints that need to be addressed. It is critical to obtain comparison weight-bearing radiographs of both feet to look for any evidence of instability. Radiographic findings of Lisfranc injury include a bony “fleck” sign and diastasis between the base of the first and second metatarsals, and/or widening between the medial and middle cuneiforms (Figure 1).

Stress testing can help reveal dynamic Lisfranc joint instability, as well as proximal extension of the injury into the intercuneiform joint. Stress testing involves forced pronation and adduction of the foot under live fluoroscopy. CT can be useful in cases of bony comminution and multiple fracture lines. MRI is helpful in cases of vague pain with negative radiographs and subtle displacement. However, it is important to remember both CT and MRI are static tests that cannot reveal dynamic instability patterns.

Preferred surgical timing is within 2 weeks of the initial injury when swelling has subsided and skin wrinkles have returned to the dorsum of the foot.

Approach and joint inspection

In the OR, the patient should be positioned supine with the foot at the end of the bed on an elevated platform above the contralateral limb to assist with lateral fluoroscopy. A bump is placed under the ipsilateral hip to obtain a neutral foot rotation with the foot pointed directly toward the ceiling. A nonsterile thigh or ankle tourniquet can be used. A thigh tourniquet has the advantage of reducing the amount of tension placed on the flexor tendons that can influence intraoperative assessment of foot alignment.

Fluoroscopy is first used to identify the first-second intermetatarsal and intercuneiform joints. A 3-cm longitudinal incision is made over the dorsomedial midfoot, centered over the Lisfranc joint (Figure 2) and the neurovascular bundle is identified and carefully retracted laterally. A small pituitary is used to clear away all interposed debris from the Lisfranc joint along with the intercuneiform joint, as needed. A freer is placed in each joint to assess any instability and chrondral injuries under direct visualization. Care must be taken to not remove excessive capsule from the first tarsometatarsal (TMT) joint because this can cause iatrogenic instability.

incision is made over the dorsomedial midfoot
A 3-cm longitudinal incision is made over the dorsomedial midfoot centered over the Lisfranc joint (a) and the neurovascular bundle is identified and retracted laterally (red arrow) (b). A small pituitary is used to gently remove interposed tissue from the Lisfranc joint (c) and a freer is placed in the Lisfranc joint and intercuneiform joint to assess for instability under direct visualization (d), as well as under fluoroscopy (e). Inspection of the joint after debridement often reveals gross instability with potential chondral injury (f).

Joint reduction

Screw placement
Screw placement can be facilitated through use of a targeting jig, the Charlotte Lisfranc Reconstruction System (Wright Medical Technology Inc.) (a). The targeting jig hook is placed over the proximal aspect of the second metatarsal and the sharp end of the jig is placed over the central third of the medial cuneiform. AP (b) and lateral views (c) are taken to confirm proper jig alignment. A guide wire is passed through the targeting jig from the proximal aspect of the medial cuneiform to the distal-lateral aspect of the second metatarsal base followed by over-drilling across four cortices (d). A solid 4.5-mm screw of the appropriate length is inserted and the jig is removed and placed around the central-lateral aspect of the middle cuneiform and the central-medial aspect of the medial cuneiform (e). Jig placement is confirmed on AP (f) and lateral views (g) followed by guide wire insertion, measurement, over-drilling and insertion of a solid 3.7-mm screw.

Once all joints are debrided and evaluated, interosseous transarticular solid-screw fixation is recommended to rigidly maintain reduction of the Lisfranc joint while the ligament heals and to decrease the risk of later screw breakage. In proximal medial-column variants of these injuries, it is important to perform fixation across the medial and middle cuneiforms, as well as between the medial cuneiform and base of the second metatarsal (“home run” Lisfranc screw). Screw placement can be facilitated through use of a targeting jig, in this case with the Charlotte Lisfranc Reconstruction System (Wright Medical Technology Inc.).

The targeting jig hook is placed over the proximal aspect of the second metatarsal, ensuring the hook is under the neurovascular bundle and directly on bone (Figure 3). The sharp end of the targeting jig is then placed over the central third of the medial cuneiform on anteroposterior (AP) and lateral views and the Lisfranc joint is reduced by squeezing the arms of the jig together by hand or with an external clamp. Fluoroscopy is checked to confirm proper joint reduction prior to final tightening. It is important to visually inspect the Lisfranc joint to ensure the base of the second metatarsal is not over-compressed and elevated dorsally. A small 5-mm incision is made where the inner trochar of the targeting jig touches the skin, which allows for the passage of wire, drill and screws.

Screw placement

radiographs are checked for screw placement and length
Final AP (a) and lateral (b) radiographs are checked for screw placement and length. The Lisfranc and intercuneiform joints are reassessed to confirm proper joint reduction (c). The wound is closed in a layered fashion followed by placement of a NWB posterior mold splint (d).

A guide wire is passed through the targeting jig from the proximal aspect of the medial cuneiform to the distal-lateral aspect of the second metatarsal base, mimicking the course of the Lisfranc ligament. The guide wire is measured using a depth gauge and screw length should err on the short side, as needed. The guide wire is then over-drilled across four cortices and the wire and drill are then completely removed. A solid 4.5-mm screw of the appropriate length is then inserted through the jig and tightened completely. This screw is essentially extra-articular, avoiding the first and second TMT joints.

An intercuneiform screw is then placed using the targeting jig as described above or using a freehand technique. The hook end of the jig is placed around the central-lateral aspect of the middle cuneiform and the sharp end is placed over the central-medial third of the medial cuneiform. Jig placement is checked on fluoroscopy followed by guide wire insertion, measurement, over-drilling and insertion of a solid 3.7-mm screw. It is important to avoid using a screw that is excessively long because the tip of the screw can penetrate the middle-lateral cuneiform joint and the screw head can irritate the medial soft tissues.

After final screw placement (Figure 4), the Lisfranc and first TMT joints should be reassessed for any residual instability. Continued instability can be addressed with 2.4-mm to 2.7-mm bridge plates with two screws on either side of the joint, as needed. Although bridge plates are typically removed after 3 months to 6 months, solid screws can be left in patients forever depending on patient preference. Premature hardware removal can lead to loss of reduction and recurrent diastasis, particularly at the intercuneiform joint.

The wound is irrigated with normal saline and then closed in a layered fashion. Care should be taken to not grab the neurovascular bundle. A sterile, soft, dressing is applied followed by a non-weight-bearing (NWB) posterior mold splint.

Rehabilitation

10 weeks after surgery
AP (a) and lateral radiographs (b) 10 weeks after surgery demonstrate maintained reduction of the Lisfranc and intercuneiform joints without recurrent diastasis. The patient was able to return to running at 12 weeks after surgery with full RTP at 5 months postoperatively.

Patients are kept NWB in a splint for 2 weeks after surgery followed by suture removal and NWB in a tall CAM boot that is worn from 3 weeks to 4 weeks postoperatively. Progressive weight-bearing and range of motion exercises are initiated from 4 weeks to 8 weeks, followed by return to accommodative shoe wear from 10 weeks to 12 weeks (Figure 5). Running is permitted at 12 weeks postoperatively, but cutting and sprinting activities are restricted until after 16 weeks. The RTP for most athletes occurs 5 months to 6 months after surgery and final functional outcome is related to the adequacy of the initial reduction and the severity of the initial injury.

Disclosure: Hsu reports he is a paid presenter/speaker for Arthrex.

Andrew R. Hsu
Andrew R. Hsu

Lisfranc injuries encompass any bony or ligamentous damage that involves the tarsometatarsal joints. Traditionally, these injuries are thought to occur during axial loading of a fixed, plantar-flexed foot, but athletes can often have noncontact twisting injuries that cause Lisfranc disruption. This is particularly true in soccer and American football, where athletes plant their cleats in the ground and pivot around a fixed point in the midfoot. Lisfranc injuries are the second most common foot injury among collegiate football players, and it is estimated that up to 20% of Lisfranc injuries are missed, particularly in the purely ligamentous variants found in athletes and lower-energy injury situations. Clinically, patients often report painful weight-bearing, inability to perform a single-limb heel rise, plantar ecchymosis, and swelling and point tenderness across the bases of the first and second metatarsals.

In athletes, proximal-medial column Lisfranc variants are a common injury that need to be recognized and appropriately managed early. In these injuries, the force imparted to the foot disrupts the Lisfranc joint, extends proximally through the intercuneiform joint and exits out the naviculo-medial cuneiform joint, which causes instability at multiple joints and an unstable first ray. Radiographs are often negative, but stress views can show widening at the intercuneiform or naviculo-medial cuneiform joints. MRI of the foot often reveals edema at the naviculo-medial cuneiform joint. Unrecognized or untreated instability can lead to chronic pain, disability and deterioration of the naviculo-medial cuneiform joint.

One of the clinical decision-making difficulties with Lisfranc injuries is there are no exact diastasis parameters to guide surgery. Patients should be treated based on symptoms, functional needs and degree of instability. It has been shown that patients with up to 5 mm of displacement can still have good long-term clinical results, in select cases, without surgery. Nonoperative treatment is indicated in cases without instability or displacement and this involves protected weight-bearing in a tall controlled-ankle motion (CAM) boot for 4 weeks followed by a progressive increase in activities with return to play (RTP) typically at 6 weeks to 8 weeks after injury.

The goal of surgical intervention is to obtain and maintain anatomic reduction of all unstable midfoot joints in order to restore normal foot mechanics. To obtain a successful outcome, it is important during surgery to remove all interposed soft tissue debris from the Lisfranc joint and directly assess the articular surfaces before placing solid screws and/or plates.

PAGE BREAK

Surgical technique work-up

 a non-contact twisting injury to the foot
Standing AP radiograph of a 33-year-old female soccer player after a non-contact twisting injury to the foot on artificial turf shows diastasis between the bases of the first and second metatarsals with a positive “fleck” sign indicated by the red arrow (a). Coronal MRI shows plantar edema and disruption of the Lisfranc ligament ( red arrow) (b). Sagittal MRI demonstrates proximal edema extending to the naviculo-medial cuneiform joint (red arrow) (c). Ligamentous stability before (d) and after (e) pronation and adduction stress testing of the midfoot under live fluoroscopy shows Lisfranc and intercuneiform instability (red arrows).

Images: Hsu AR

Prior to surgery, it is important to perform a thorough history and physical exam to determine the exact nature of the Lisfranc injury and all the unstable joints that need to be addressed. It is critical to obtain comparison weight-bearing radiographs of both feet to look for any evidence of instability. Radiographic findings of Lisfranc injury include a bony “fleck” sign and diastasis between the base of the first and second metatarsals, and/or widening between the medial and middle cuneiforms (Figure 1).

Stress testing can help reveal dynamic Lisfranc joint instability, as well as proximal extension of the injury into the intercuneiform joint. Stress testing involves forced pronation and adduction of the foot under live fluoroscopy. CT can be useful in cases of bony comminution and multiple fracture lines. MRI is helpful in cases of vague pain with negative radiographs and subtle displacement. However, it is important to remember both CT and MRI are static tests that cannot reveal dynamic instability patterns.

Preferred surgical timing is within 2 weeks of the initial injury when swelling has subsided and skin wrinkles have returned to the dorsum of the foot.

Approach and joint inspection

In the OR, the patient should be positioned supine with the foot at the end of the bed on an elevated platform above the contralateral limb to assist with lateral fluoroscopy. A bump is placed under the ipsilateral hip to obtain a neutral foot rotation with the foot pointed directly toward the ceiling. A nonsterile thigh or ankle tourniquet can be used. A thigh tourniquet has the advantage of reducing the amount of tension placed on the flexor tendons that can influence intraoperative assessment of foot alignment.

PAGE BREAK

Fluoroscopy is first used to identify the first-second intermetatarsal and intercuneiform joints. A 3-cm longitudinal incision is made over the dorsomedial midfoot, centered over the Lisfranc joint (Figure 2) and the neurovascular bundle is identified and carefully retracted laterally. A small pituitary is used to clear away all interposed debris from the Lisfranc joint along with the intercuneiform joint, as needed. A freer is placed in each joint to assess any instability and chrondral injuries under direct visualization. Care must be taken to not remove excessive capsule from the first tarsometatarsal (TMT) joint because this can cause iatrogenic instability.

incision is made over the dorsomedial midfoot
A 3-cm longitudinal incision is made over the dorsomedial midfoot centered over the Lisfranc joint (a) and the neurovascular bundle is identified and retracted laterally (red arrow) (b). A small pituitary is used to gently remove interposed tissue from the Lisfranc joint (c) and a freer is placed in the Lisfranc joint and intercuneiform joint to assess for instability under direct visualization (d), as well as under fluoroscopy (e). Inspection of the joint after debridement often reveals gross instability with potential chondral injury (f).

Joint reduction

Screw placement
Screw placement can be facilitated through use of a targeting jig, the Charlotte Lisfranc Reconstruction System (Wright Medical Technology Inc.) (a). The targeting jig hook is placed over the proximal aspect of the second metatarsal and the sharp end of the jig is placed over the central third of the medial cuneiform. AP (b) and lateral views (c) are taken to confirm proper jig alignment. A guide wire is passed through the targeting jig from the proximal aspect of the medial cuneiform to the distal-lateral aspect of the second metatarsal base followed by over-drilling across four cortices (d). A solid 4.5-mm screw of the appropriate length is inserted and the jig is removed and placed around the central-lateral aspect of the middle cuneiform and the central-medial aspect of the medial cuneiform (e). Jig placement is confirmed on AP (f) and lateral views (g) followed by guide wire insertion, measurement, over-drilling and insertion of a solid 3.7-mm screw.

Once all joints are debrided and evaluated, interosseous transarticular solid-screw fixation is recommended to rigidly maintain reduction of the Lisfranc joint while the ligament heals and to decrease the risk of later screw breakage. In proximal medial-column variants of these injuries, it is important to perform fixation across the medial and middle cuneiforms, as well as between the medial cuneiform and base of the second metatarsal (“home run” Lisfranc screw). Screw placement can be facilitated through use of a targeting jig, in this case with the Charlotte Lisfranc Reconstruction System (Wright Medical Technology Inc.).

The targeting jig hook is placed over the proximal aspect of the second metatarsal, ensuring the hook is under the neurovascular bundle and directly on bone (Figure 3). The sharp end of the targeting jig is then placed over the central third of the medial cuneiform on anteroposterior (AP) and lateral views and the Lisfranc joint is reduced by squeezing the arms of the jig together by hand or with an external clamp. Fluoroscopy is checked to confirm proper joint reduction prior to final tightening. It is important to visually inspect the Lisfranc joint to ensure the base of the second metatarsal is not over-compressed and elevated dorsally. A small 5-mm incision is made where the inner trochar of the targeting jig touches the skin, which allows for the passage of wire, drill and screws.

PAGE BREAK

Screw placement

radiographs are checked for screw placement and length
Final AP (a) and lateral (b) radiographs are checked for screw placement and length. The Lisfranc and intercuneiform joints are reassessed to confirm proper joint reduction (c). The wound is closed in a layered fashion followed by placement of a NWB posterior mold splint (d).

A guide wire is passed through the targeting jig from the proximal aspect of the medial cuneiform to the distal-lateral aspect of the second metatarsal base, mimicking the course of the Lisfranc ligament. The guide wire is measured using a depth gauge and screw length should err on the short side, as needed. The guide wire is then over-drilled across four cortices and the wire and drill are then completely removed. A solid 4.5-mm screw of the appropriate length is then inserted through the jig and tightened completely. This screw is essentially extra-articular, avoiding the first and second TMT joints.

An intercuneiform screw is then placed using the targeting jig as described above or using a freehand technique. The hook end of the jig is placed around the central-lateral aspect of the middle cuneiform and the sharp end is placed over the central-medial third of the medial cuneiform. Jig placement is checked on fluoroscopy followed by guide wire insertion, measurement, over-drilling and insertion of a solid 3.7-mm screw. It is important to avoid using a screw that is excessively long because the tip of the screw can penetrate the middle-lateral cuneiform joint and the screw head can irritate the medial soft tissues.

After final screw placement (Figure 4), the Lisfranc and first TMT joints should be reassessed for any residual instability. Continued instability can be addressed with 2.4-mm to 2.7-mm bridge plates with two screws on either side of the joint, as needed. Although bridge plates are typically removed after 3 months to 6 months, solid screws can be left in patients forever depending on patient preference. Premature hardware removal can lead to loss of reduction and recurrent diastasis, particularly at the intercuneiform joint.

The wound is irrigated with normal saline and then closed in a layered fashion. Care should be taken to not grab the neurovascular bundle. A sterile, soft, dressing is applied followed by a non-weight-bearing (NWB) posterior mold splint.

PAGE BREAK

Rehabilitation

10 weeks after surgery
AP (a) and lateral radiographs (b) 10 weeks after surgery demonstrate maintained reduction of the Lisfranc and intercuneiform joints without recurrent diastasis. The patient was able to return to running at 12 weeks after surgery with full RTP at 5 months postoperatively.

Patients are kept NWB in a splint for 2 weeks after surgery followed by suture removal and NWB in a tall CAM boot that is worn from 3 weeks to 4 weeks postoperatively. Progressive weight-bearing and range of motion exercises are initiated from 4 weeks to 8 weeks, followed by return to accommodative shoe wear from 10 weeks to 12 weeks (Figure 5). Running is permitted at 12 weeks postoperatively, but cutting and sprinting activities are restricted until after 16 weeks. The RTP for most athletes occurs 5 months to 6 months after surgery and final functional outcome is related to the adequacy of the initial reduction and the severity of the initial injury.

Disclosure: Hsu reports he is a paid presenter/speaker for Arthrex.