38: Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation

PROCEDURE 38 Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation



Rajrishi Sharma, Brad Petrisor



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Indications



image The treatment goals for tarsometatarsal (TMT) joint injuries are to obtain proper joint alignment and congruity and maintain joint stability.

image Nonoperative treatment is preferred for patients with TMT joint sprains.
• These are defined as pain on weight bearing and palpation without any radiographic instability, and nondisplaced ligamentous injuries.

• The indications for nonoperative treatment include less than 2 mm of displacement in any plane and no joint line instability with weight-bearing or stress radiographs.

• These injuries can be treated in a short-leg non–weight-bearing cast for 6 weeks with repeat stress views 10 days postinjury.

• These patients can progress to active rehabilitation only when they can perform a single-leg heel rise without pain.

image If there is any presence of deformity or instability greater than 2 mm, anatomic reduction is required.


Examination/Imaging



PHYSICAL EXAMINATION



image Pain, swelling, or echymosis over any area of the TMT joint complex is usually present (Fig. 1A and 1B).

image Pain with passive dorsiflexion or plantar flexion of individual metatarsal (MT) heads or pain in the midfoot with attempted single-leg heel rise can point to a Lisfranc injury.

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FIGURE 1



IMAGING STUDIES



image Radiographic investigations include plain radiographs, stress radiographs, and computed tomography scans.
• Generally, plain radiography is sufficient for the diagnosis of a Lisfranc injury.

• Anteroposterior (AP), lateral, and 30° internal oblique radiographs are necessary to adequately assess the forefoot.

image On plain radiographs, the following relationships should be maintained in the normal foot:
• Anteroposterior (Fig. 2A)
♦ The first MT aligns with the medial cuneiform both medially and laterally.

♦ The medial border of the second MT should be aligned with the medial edge of the middle cuneiform.

• Lateral (Fig. 2B)
♦ The second TMT joint aligns on its dorsal surface uninterrupted with the tarsal bone proximally and the MT base distally.

♦ Dorsal displacement of the MT is abnormal.

♦ Plantar displacement of less than 1 mm is normal.

• 30° internal (medial) oblique (Fig. 2C)
♦ This view is mainly used to assess the third, fourth, and fifth MTs.

♦ The medial border of the third MT is aligned with the medial edge of the lateral cuneiform.

♦ The medial border of the fourth MT is aligned with the medial border of the cuboid.

image Any disturbance of the normal alignment on any one radiographic investigation may indicate a Lisfranc injury.
• Avulsion fractures around the TMT joint—the “fleck” sign: an avulsion of the medial base of the second MT from the attachment of the Lisfranc ligament, as seen in Case 1 (Fig. 3A and 3B)

• Widening of first MT interspace

• Fracture of the second MT base

• Crush injury to the cuboid or medial cuneiform, as seen in Case 2 (Fig. 4A and 4B)

• Fracture of the navicular tuberosity

image Stress views can be performed to further assess the stability of the TMT complex. This can be done with the hindfoot stabilized and forefoot placed in supination/pronation or adduction/abduction.
• Displacement greater than 2 mm of widening between the bases of the first and second MTs is considered ligamentous compromise.

• Weight-bearing views can also be used to stress the longitudinal arch and assess for widening of the first intermetatarsal space.

image Computed tomography—both standard (Fig. 5A) and three-dimensional (Fig. 5B), as for Case 1—can also be used to better evaluate subtle Lisfranc injuries or for preoperative assessment of other concurrent fractures.

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FIGURE 2


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FIGURE 3


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FIGURE 4


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FIGURE 5




Treatment Options



• Options include open reduction and internal fixation or partial primary fusion (fusion of the medial column).

• Some authors suggest that pure ligamentous injuries tend toward chronic pain and instability even with initial anatomic reduction and stable fixation, and suggest primary fusion for these injuries (Coetzee and Ly, 2007; Ly and Coetzee, 2006).


Surgical Anatomy



image The TMT joint is complex and is divided into the medial and lateral columns (Fig. 6).
• The medial column is further divided into the medial and middle legs.
♦ The medial leg includes the first MT and medial cuneiform. This leg has three times more motion than the middle leg.

♦ The middle leg comprises the second and third MT and the middle and lateral cuneiforms. This leg is rigid; it acts as the fulcrum against which the middle leg and lateral columns move.

• The lateral column, consisting of the fourth and fifth MT and the cuboid, is the mobile unit of the forefoot and is critical for a comfortable gait.

image The stability of the transmetatarsal arch is derived from the Roman arch keystone effect at the base of the second MT.
• The second MT is dovetailed and recessed compared to the first MT by 1 cm and compared to the third MT by 0.5 cm.

image Additional stability of the TMT joint complex is provided by the dorsal and plantar interosseous capsuloligamentous restraints (Fig. 7A and 7B).

image The bases of the second through fifth MTs are bound by dense transverse metatarsal interosseous ligaments, with the dorsal ligaments weaker than the plantar ones.

image There is no intermetatarsal ligament between the first and second MT.

image The base of the second MT is joined to the first TMT joint by a medial interosseous ligament connecting the medial plantar aspect of the second MT base to the plantar lateral medial cuneiform.
• This is the largest ligament of the forefoot complex and the only support between the medial leg and the middle leg and lateral column.

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 38: Repair of Tarsometatarsal Joint (Lisfranc) Fracture-Dislocation

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