Tarsometatarsal (Lisfranc) Reduction and Fixation

John S. Early

Harold B. Kitaoka

John T. Campbell

Lisfranc injury refers to a broad spectrum of injury patterns involving the tarsometatarsal (TMT) joints of the foot (Fig. 17.1A). They can be represented by subtle soft tissue instability or complete transverse dislocation with significant bony injury (1, 2 and 3). The area of instability covers not only the TMT joints but also the intercuneiform joints, the cuneiform navicular joints, and the cuboid articulations with both the lateral cuneiform and the calcaneus (Fig. 17.1B-E). The pattern of injury depends on the force applied to it (4). The combination of translation and axial forces on this area of the foot creates the varied injury patterns so often discussed. The diagnosis of TMT injury is usually straightforward. A patient presents with pain in the TMT area with forefoot weight bearing. These injuries need to be protected from weight bearing until the pain resolves. The issue from a surgical standpoint is which of these injuries are unstable and which joints need to be fixed.

When a patient presents with symptoms consistent with a Lisfranc injury, careful evaluation is needed. Decisions about surgery in the acute setting are based on documented instability. Singlelimb weight-bearing AP, lateral, and medial oblique films of the injured foot should be done to assess stability (Fig. 17.2). If the patient is unable to stand due to other injuries, a stress view should be obtained to evaluate joint integrity. A bilateral weight-bearing AP view of the feet is also helpful to evaluate subtle asymmetries (Fig. 17.3).

Stable Lisfranc injuries do not require fixation. These patients are treated with a cast or boot initially non-weight bearing and eventually with rehabilitation back to their desired activity level. The goal in the unstable injury is to recreate the stable bony alignment that allows the foot to transfer load from the hindfoot to the forefoot. The accepted standard management of displaced fracture dislocations is anatomic reduction and stabilization with fixation (5, 6, 7, 8 and 9). There are opinions regarding arthrodesis in the acute setting of the medial column TMT joints as a means to achieve the desired stability without the need for screw removal or the issue of late instability or arthritis (10). Pure ligamentous instability is often challenging to manage successfully as compared to combined ligament-bony injuries, with surgical decision making influenced by factors such as the extent of the injury and weight of the patient. Acute fusions are reserved for joints with severe damage to more than 50% of the articular surfaces, joints that cannot be reconstructed, and selected individuals with pure ligamentous injuries with high body mass index.

Lisfranc injuries require critical assessment of the injury pattern, restoration of anatomic alignment, and stable fixation with as little injury to joint surfaces as possible. There are multiple techniques that have been successful, including open reduction and internal fixation (ORIF) with screw fixation, and more recently, a bridging plate for indirect joint reduction and minimizing the damage to articular cartilage.

FIGURE 17.1 Lisfranc injuries. A: Drawing shows dorsal and coronal views of bone, joint, ligament anatomy of Lisfranc complex.

FIGURE 17.1 (Continued) B: Isolated disruption of second TMT joint. C: Severe disruption of Lisfranc complex including medial cuneiform. D: A more subtle Lisfranc injury with intercuneiform instability. E: Subtle Lisfranc injury with medial cuneiform subluxation and fracture. Note first and second TMT joints are at about the same level.

FIGURE 17.2 Radiographs of a 15-year-old boy who fell down stairs in the dark while texting. He presented with pain, swelling, and ecchymosis. All five TMT joints were unstable. A: AP foot radiograph. B: Lateral view. C: Oblique foot.

FIGURE 17.3 Standing bilateral AP radiograph useful for comparison, showing subtle instability of left second TMT joint.

INDICATIONS AND CONTRAINDICATIONS

The main indication for surgery is a displaced fracture dislocation of the TMT joints. This often involves the first and second TMT joints, and sometimes the remaining TMT joints and more proximal joints. These often are mostly ligamentous injuries with minor fragments of bone fractured, but can also be severe bony injuries with multiple fractures of the metatarsals and cuneiforms. Relative contraindications include patients with severe soft tissue injury with massive swelling. Other factors that require clarification before surgery is considered are patient compliance, evidence of peripheral neuropathy, and dysvascular extremity.

PREOPERATIVE PLANNING

Weight-bearing foot radiographs or stress films of the foot are used to confirm the diagnosis of Lisfranc injury. The extent of the injury needs to be fully appreciated to plan treatment. Depending on the force of the initial trauma (auto injury, fall from a height, or twisting injury), assessment of the vascular status of the foot as well as compartment pressures should be considered. The presentation of an acutely swollen foot with a Lisfranc injury may in fact be due to the dorsal dislocation of the metatarsals, and urgent reduction may be indicated to protect the soft tissues from pressure necrosis. If evidence of compartment syndrome of the foot exists, steps should be taken to plan on stabilization of the unstable joints at the time of the fascial release to minimize repetitive injury to the soft tissues by returning later for stabilization. Reduction and fixation is easiest while the tissues are supple. For simple instability, no further radiographic studies are needed, but in more complex injuries or when there is suspected bony injury, CT scans can be important to overall surgical planning (Fig. 17.4).

SURGICAL TECHNIQUES

Technique 1: ORIF with Screw Fixation

The patient is placed supine upon the operating table with a roll beneath the hip to point the toes to the ceiling and a platform or stack of blankets under the foot and distal tibia to elevate the foot above the other for easier lateral fluoroscopic views during surgery. The fluoroscopic unit is placed so that the screen is at the foot of the operating table, and the fluoroscopic unit is placed on the contralateral side so as not to interfere with surgical access or fixation.

FIGURE 17.4 Computed tomography scanning to assess extent of bony injury showing fractures of first, second, and third metatarsal bases with joint disruption. A: Axial view. B: Coronal view more distal, at the level of the first TMT joint. C: Coronal view more proximal, at the medial cuneiform level.

FIGURE 17.4 (Continued) D: Sagittal view.

The equipment posted for this case depends on surgeon preference but is most often done with 3.5-cortical fixation screws. Smaller screws and plates are also requested if there are adjacent fractures that will need attention at the time of surgery.
The limb is prepped and draped to allow access to the proximal tibia in the rare case of graft being need to fill gaps. A high thigh tourniquet is placed for hemostatic control. The limb is exsanguinated with an elastic bandage prior to inflating the tourniquet.

The approach for each case is determined by the pathology involved to enable direct visualization of the area requiring reduction. The vast majority of these injuries involve the second TMT instability, so the primary skin incision is placed along the medial border of the second metatarsal from the level of the navicular distal to the midportion of the second metatarsal (Fig. 17.5A). The dissection is continued vertically to the level of the dorsal ligaments. Care is taken to identify and protect the sensory nerve branches (Fig. 17.5B), dorsalis pedis artery, and extensor hallucis brevis tendon.

FIGURE 17.5 A: Dorsal longitudinal incision between first and second metatarsals. B: Nerves crossing the Lisfranc joints— saphenous, deep peroneal, medial dorsal cutaneous nerve, and intermediate dorsal cutaneous nerve.

At this level, the extent of the disruption is readily apparent (Fig. 17.6). Direct inspection of the dorsal ligamentous integrity for all the surrounding joints is undertaken so that unstable joints are identified and only those found to be unstable receive fixation. The disrupted joint surfaces are inspected and chondral lesions and small bone fragments débrided. Plantar extra-articular fragments are left in place as long as they do not block reduction.

Debridement of the Lisfranc ligament may be necessary to allow anatomic reduction of the second metatarsal to the medial cuneiform. Care should be taken not to débride too aggressively for adequate soft tissue healing in and around the ligament.