Benjamin Overley, Jr, DPM reviews surgical techniques commonly used for Lisfranc injuries and provides clinical pearls while reviewing multiple cases that he has encountered in his practice.
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Benjamin Overley, Jr, DPM
Surgical Skills Committee
Section Editor for Trauma-Journal of Foot and Ankle Surgery
Foot and Ankle Specialist/PMSI Orthopedics
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Male Speaker: Okay, so, when you talk about Elizabeth Francis here, these Lisfranc injuries, and we always think about them in associate. There are obviously football career enders. This is the runningback that gets hit as he’s trying to make a cut, somebody falls on his foot and it’s in that hyperflexed position. Another thought is the wide receiver is trying to stay in bounds and goes up on tiptoes, gets piled into from behind, feet go under. But even though when we take a look at Lisfranc’s injuries and we say, well, males are two to four times more than females, not in my population. Typically, the female I see with this injury is going to be somebody that falls down the steps, usually with a laundry basket and their foot falls under and it’s oftentimes missed. Why do we miss these things, because we really don’t look at that. Remember that in emergency room, you’re getting an x-ray and these x-ray is going to maybe teleradiologist, maybe you’re lucky and that radiologist happens to be on the same campus as you. But for the most part, they don’t have a patient in front of them to actually look at and examine. So it’d really be who’s you to look at these things. As soon as they say, I was walking down something and my toes went under me, the first thing you should be doing is looking at that Lisfranc’s joint. Now, the purpose of this discussion or the purpose of this presentation has been a topic that is raged since I was a student and I’m sure before I was a student continues to rage on today. When do we pull the trigger on fusing them? Do we do it right away? Do we wait three months? Do we wait a year? Do we put screws in? Do we put an x-fix on? Do we put pins in? This is really where we get into these issues with, you know, sometimes, not really agreeing even within our own minds on what’s the best course of action is. So, this is pretty simplistic indirect, obviously indirect crash injuries, such as high energy MVAs. You see a bow like this and you immediately think SS Kalish and then you think who’s got the potential to run into SS Kalish, and that would be Schoenhaus. But we all know that Schoenhaus would never drive a vehicle like that. So if it was a Maserati, that would be more plausible. So as we know with this [indecipherable] [02:15] and tailor made sponsorship. So, Charcot, we’re not going to go there. Marie touched on this earlier. This is really sort of its own animal, so we’re going to take that out of play right now and not even listen to it or talk about it. But high energy MVAs, patient is driving and comes to an abrupt stop, slams in the brakes, runs into something, think about the foot position when that happens, metatarsals are loaded. Where is it force transmission? It’s going to be the tarsometatarsal joint. Taking a look at these, and these are really the parameter players. I mean, clearly, if we’ve got bones that are fractured and the foot looks so deformed and we’re going to look at it and we go, “Wow. That’s a Lisfranc’s.” But that’s not the majority of them. In fact, it’s a very small percentage of them. These are really the customers that you’re going to be seeing, and if you’re not seeing them, they’re seeing you. So bear that in mind. These patients are moving through your office hours and your clinic hours, complaining a midfoot pain that you may be misconstruing for something else completely, hypermobile first ray or something. Are you sure? Because if you think about it, these patients you put them in a boot, you do all these things, you put them in a cast, you send them for PT, which they really can’t tolerate and they’re still not getting any better. This is sort of like the syndesmotic injury of the foot if you think about it that way. If you don’t see any of these things, you don’t see fractures, you don’t see really displacement, they’re very subtle and they’re very quiet. So really where do we go with these? This really has been a controversy for a long time as I said. What’s the timing on it? From my perspective and based on the literature, if it is a full five dislocation with no bony involvement, so we’re talking no fracture but all the five tarsometatarsal joints have been violated, those are individuals who I’m going to pin four and five and I will do a primary fusion because I have no stability left. Simply just pinning them or putting screws across that you’re going to take out on a later date does not do the job. So you have to make sure in these individuals that that type of patient is going to, in most cases, in my hands, going to get a fusion. Now, postoperative management, when do we let them walk? Well, I think that’s kind of based on the severity of it. Obviously, if there’s a lot of intraarticular fragments, that particular joint will get fused primarily. Well, for fusing that one primarily, and the second one doesn’t have it, but we’re staring at the second one because we’re working on the first, why do we just fuse the second? Well, clearly, if that’s the case, I think you should do that because you’re already looking at it, number one, and number two, think about what’s going to happen biomechanically once you fuse the first? But you’ve got a weakened second tarsometatarsal joint, your first you fuse, you’ve locked that up metallically but your second is still free floating.
So what’s the potential that they’re going to have problems at that down the line? So, again, if you use common sense with these things, you usually can figure them out. Need for removal of hardware. I typically don’t remove it. There are some people that say five months, three months, and it depends on who you talk to as to whether you take the stuff out ever or when you take it out. And the same debate rages on with syndesmotic screws, what’s the acceptable timeframe? Nobody really knows. I’m taking out syndesmotic screws in the ankle and watch them spring open, two, three months, 10 months later, and I thought they were healed. So why do we take them out? We take them out in the foot because we’re worried about them breaking. Well, if they break and you have to go in and fuse it, you’re going to go in and fuse it anyway. You understand what I’m saying? So, I mean, the point this kind of lost to me why we remove this stuff at all. I really don’t understand. We’re almost like daring. We’re daring that injury to rehappen again or if that patient have pain again. We’re challenging ourselves when we don’t need to. There’s no reason to take this stuff out. This was a hot topic at AOS last week, the spanning plates. We’re not going to fuse, but we’re also not going to violate any joint space, we’re just going to basically drop screws around the joint and kind of just like cowboys and Indians just sort of surround the thing. If we can do that, and we can surround that deformity and we hold it in place, then maybe we’ve engendered some stability and we don’t have to do anything in terms of fusion because we have enough stability going for us. Of course, these endobuttons, you heard Dr. Kalish [phonetic] talk about that earlier and with hallux valgus correction. Obviously, they do have a role here. The only thing that I would point you to is there is going to be some slight diastasis. It is not the same as metal. I would reserve this from my younger, more active patient because that I want more flexibility down the line. Those patients, I don’t like throwing screws into. I don’t like throwing screws into a 22-year-old with a Lisfranc’s injury. So this might be a good option for them that is going to give them a lot better, long-term prognosis. So again, going back to primary arthrodesis, well, that’s pretty simple. If you see something like this, you’re going to have to be doing fusions. If we look at the functional scores, if we do one, two, three versus one, or three, but we leave two alone or any combination thereof, if we just go ahead and lock those three up, we usually do pretty good with them right off the bat. You can see here, we got a screw trying to leave town on us here, probably a little bit too close to the joint but this is obviously something that you’re going to go ahead and remove. So when we look at the dissection planes, clearly, these are areas where we’re going to be working in very tight quarters. There’s a lot of structures here we don’t want to hit. So we need to make sure that we don’t. Leaving an adequate skin bridge in between our incision planes is definitely going to give us a lot more success. But what happens if you got a patient like this where if you’ve got Lisfranc’s involvement where you’ve got this displaced fracture and we’ve got a really doughy blown out foot? So this is a perfect indication for what Marie talked about earlier, is using percutaneous reduction, trying to pull things back out, you’re going to see a percutaneous Hindermann type or joint distractive device. Then in addition, placing external fixation on that to stabilize the region. So you’re going to see what it looks like from a video perspective. Can you get that out? Thank you. Sorry about the blurriness there on the first picture. Some companies have these devices with clamps that are built in. I just like using this sweetheart tenaculum to pull things together. You can see even in my hands, and you mismeasure this sometimes, you go in and you place the screw and you think that’s going to be long enough. You can see here, as I’m driving that screw, I’m trying to get a really good bite into that first cuneiform bone but I’m just coming up short. I’m right passing cuneiform joint. I know that’s not going to be stable. So I’m going to go ahead and pull that out. There’s nothing wrong with redirecting, getting yourself a longer screw. But this a case where we’re dealing with one, two, and three here and that one is dislocated as well, but I’m a lot of real estate, so I’m going to try to do just try to stabilize them and bring them back in. You see me putting in the final screw. You notice, I put it on power. These are not going in by hand. I think there’s too much torque and rotation with hand movement. I want my screws to go in like that. Every time you do this, you make your screw hold bigger.
So I want this to be really snuggly and you can see the final construct for that. Here we go. This is what we look at. We’re looking at this in the operating room. This is what we typically see with Lisfranc’s patients. They’re going to have an abducted forefoot, why? Because this has been violated. Their forefoot, they probably walk on a little bit after their injury, so all the mets are going to drift off laterally but the rest of their foot is going to be going north south, while the forefoot is kind of going northwest or northeast. This is what you typically see that sort of that mild abductory angle. So that was the individual I just showed you. Now, I didn’t fuse that individual, that was all just screw fixation. You look at that, this was a, I think, three or four months post up when I discharged him. Now, this was an interesting case because this individual, I seem to draw an inordinate amount of Center for Behavioral Health Patients and this was a, I don’t want say, a dump from one of my orthopedic colleagues, but let’s just say he didn’t feel comfortable dealing with this patient. So this was a Saturday night, 11:00, a night phone call, “Oh, I got a great case for you. Thanks.” So you go in the next day, you see him, he’s not only on the CBM for paranoid schizophrenia but he’s also a diabetic. So this is not an individual I’m contemplating for an initial fusion but I just said, the functional scores of one, two, three fusions are much better than if I fix them. Well, and this individual, he’s low demand. He’s really only demand is being able to get to the backdoor fast enough to make sure his home is still safe and that’s literally how he injured himself. So, all I’m trying to do is focus on stabilizing these three columns, okay. Right here, you see, I left four and five alone. I didn’t even touch it. I get asked all the time, “Well, do you fuse four and five, that cuboid metatarsal articulation as it were?” I think there are cases, especially a neuropathic patients where I think that’s probably the best thing to do. I think though if the patient is not neuropathic, which this individual is not, I really try to leave these things alone. The most I will do is put Kirschner wire fixation in that I will remove at a later date. This does not make me comfortable in a patient that has sensation, again, much like the pantalar. But you can see here, that’s the construct. If you look at his medial longitudinal arch is very good. He hasn’t had collapse and he’s doing quite good. In this x-ray, he’s walking. I mean, this is his standing x-ray in my office. So doing quite good. So this is an individual, again, going back to my other two talks and talking about patient selection, which by the way, in any of these cases is I still get burned. There’s people you want to help and they still burn you and there’s other people where they just burn you just on face value. But here’s an individual who could not tell me whether or not, he told me when I saw him and you’re going to see in the upcoming slides the significance of this gentleman’s deformity is pretty obvious. So this was clearly Lisfranc’s, but he didn’t remember whether he had fallen off a motorcycle or somebody had hit him with an axe or a combination thereof. So this is not an individual that you probably are going to want to reconstruct his midfoot and luckily by saving grace, he had some other issues and he was scheduled for surgery but you look at something like that, look at the boldest nature. And what happens overtime is that foot deforms and that lateral drift begins to really occur. Look at that. I mean look at it from behind. I mean, that is really, really prominent deformity here. Clearly, he had a missed Lisfranc’s and that was never addressed. So when we take a look at the approaches, you can approach them any different way that you want. Some people like going dorsal incision, some people like medial, some like combo of both. It depends. For me, obviously, this is going to be a first tarsometatarsal joint type involvement where I’m going to use this medial longitudinal arch approach. But if it’s a second and if it’s one, two, three and four, I’m going to split the difference, air more towards the first. If I’m going to do a fusion, I’m going to air towards one and I’m going to work my way over to two because it’s a smaller joint and I can get there easier and the confines of that joint are easier for me to address because they’re much smaller. If I started two and try to work my way over to one, well, that’s a really much deeper joint and much wider joint than two is. So you sort of box yourself out with your incision sometimes. So, just be cautious with that and understand that if you’re going to do that just to sort of split the difference like this and try to really move your incisions over this way and keep that adequate skin bridge in between because we don’t want any dehiscence or wound breakdown over time. Again, sorry about the blurry nature. My circulating nurse sometimes takes pictures and she’s got a caffeine issue, so sometimes these are good, sometimes they’re not.
I mean, you can see the amount of arthritis that’s involved here. So, if you do have to do a fusion and you will have to do these fusions on these patients eventually, and again, I do a lot of labs and I meet a lot of people around the country as I go around and do labs and speak and things and I’ll say, “I never fuse those Lisfranc’s joints.” Could you show me a Lapidus? Like, I never did quite get that. It’s like, “Can you show me an apple and another apple?” But I don’t like that other apple. So, eventually, you’re going to have to fuse these. There’s just no way around it. What I would say is stabilization that intercuneiform joint, it is typically involved in this process. You must address that. You can’t just fix this and leave these little holes back here. I think if you’re going to create a stable construct for that patient to propel off of, you really need to stabilize midfoot as best as possible. But if you see in this x-ray, well what happens? When you do any of these fusions, just like with the Lapidus and we know this, we took a short first met and made it even shorter. So, be very, very cognizant when you’re doing fusions. Maybe this is an area where you might want to consider, as Marie said earlier, some sort of destruction before you go and do this. You can add in a bone graft, of course this can be tricky, an allograft or an autograft to get that link and keep it. Because what will happen is when you do these fusions, you end up actually peeking at those sesamoids, they’ll be staring at you as you’re looking at the great toe joint dorsally. So here’s a patient I did very well but you can see the deformity. This was the old days and you can see I still do variations of that. The patient’s foot and correction was great. They had a severe metallosis I think afterwards. But as you can see, I don’t have any fear of putting the amount of hardware that I need to. You want to make sure you have all these little joints that are going around, each one of them needs two planes of fixation. It is not enough just to get one. If you get one, then things spin, rotates, screws break and people don’t know why they break. Well, that’s why they break. You can see here the slide amount of divergence, but we try to get these patients back in line and you can see the collapse that occurs and what happens afterwards getting that alignment back, getting that medial and longitudinal arch back in shape. Obviously, with all these cases, and as I sort of just alluded to, you may need bone graft material whether in a wedge structural form, whether in the form of some sort of grafting material and make sure that you have it available before you take on these cases. There’s nothing worse than getting it there and needing something and then not having it. So, almost everybody has got the stuff lying around in their hospital in some form or another, just make sure that you do have and you identify it before the case starts, because you don’t want to get in there and running to an issue. You can see a case there where I’m going to be short and I’m going to use an extra wedge there to try to get that length back out and then metatarsal back down again. Using locking plate technology, clearly, we’ve come a long way with our fixation but just like orthopedist, we have a fixation with fixation. I sometimes go back and forth on trauma, whether we’re doing a greater service with these patients with using locking plate stuff and trauma scenarios or fracture scenarios. But I think in this instance, using a locking plate is certainly warranted. If not really at this point with the amount of abundance of locking technology that’s out there for us to use, it’s almost, I don’t want to say malpractice, but it’s probably ill advice not to use it. So, take a look at the patient like this. You can see the former screw holes. She's had a lot of pain here. Starts out initially with the fusion and this whole area is going to be fused. She had an navicular fracture, one, two and then all the bases are bases of one, two, and three. So, again, just throwing the whole hardware store at her but just trying to keep things aligned. What do you do with four and five? There’s a lot of things you can do with these, whether the ceramics spheres, anchovy procedures, dropping tendon in there, transferring localized tendon to drop into these spots as little spongy bouncers. I know, Dr. Schoenhaus likes to use some synthetic products in this type of scenario and the subtalar joint, the great toe joint, I believe also in this joint, folding that tissue in. Again, in terms of this, we just really want to make sure that we maintain that lateral calm. We don’t want to make things short and something like this is relatively simple. Do they really work? I’ve done a bunch of them. I’ve had varied success with them. You could see here, and even when you get done, you realize that you really shorten up the first met, which I did. So you can see the Weil-o-rama here on two through five, trying to get everything back and then really reduce and decompress those joints because they were clearly giving her a lot of problems as well.
So, here’s a case. This goes back a couple years ago. I was trying out some new hardware and, as we do, we like to try new things and this look like a really new, neat, sexy thing to use. So I thought I would use it and I probably under hardwared her. I just lectured you guys about making sure you have adequate fixation. This case, I clearly did not. So this went on to a nonunion and you will get them. So, if you’re doing these surgeries, expect that, just like any other fusions, so either osteotomy, nonunions occur. So you do sometimes have to go back in and do a hardware exchange and refuse things and she ended up doing very well in the second case. But again, really short first met. So keep that in mind when you’re doing these because you really can shorten people up a lot. Another CBM patient of mine, he was very upset that his girlfriend had left him and no longer wanted to be a part of our mortal coil at this time. He wanted to get out of here the quick way, but as usually what happens with these scenarios, they don’t. They just end up breaking everything on their way down. This was a perfect example of that. You can see the diastasis here between two and three and four. Everything is capped off, it’s sitting off to the side. He had a distal radius fracture with no DURJ involvement, that’s distal ulnoradial joint. The reason why I tell you that is that’s a very important thing to know if you’re going to do these procedures because you’re clearly going to keep them nonweightbearing. If there is a distal radial fracture or any kind of upper extremity fracture, this is going to limit their ability to get around. In his case, he was actually very unsafe from a scooter population standpoint. So, these were things that I always look at when I’m doing my trauma cases. So, has the orthopedist fixed the wrist? I come in on a Sunday, and you can see that dorsal pop up you get with all of these. Those dorsal ligaments are much thinner. They’re not as strong as the plantar ligaments because they don’t have to be. You’re walking off of these ligaments. They’re strong by their nature. These are not. So you do get that distraction, you get that pop up. You can see with the CT scan looks like obviously really dusted there, a lot of intraarticular pieces, but I talked to you about that earlier and I said, “Well, in these cases, I would definitely fuse them.” Well, I went against myself in this scenario. The reason why I’m showing you this case, so I can get up here and show you a million cases of how everything goes good for me and look at my great results, but you’re not going to learn a thing. But what you learn here is I should have fused this guy and I didn’t. So, put these screws in, I stabilized everything. This one is going first cuneiform to second, first cuneiform to third and cutting across the second and I think I have a fairly good stable construct. Alright. So we go down the line, months later, you notice these x-rays are missing something, why? Because the hardware was hurting him. Why? Because I didn’t fuse it the first time, which is what I should have done. You can see, look at the early arthrosis that’s occurring. This is within a year. This guy has got tremendous arthritis, arthrosis that’s already taken place. Then you do need to go in and you do need to do the definitive procedure that you should have done the first time, but for some reason, you didn’t do. So maybe it was just easier on a Sunday to throw screws and not do what I needed to do, but in the end, he ended up doing fine and he’s actually leading a very happy healthy life now. Thank God. But you do have to go back and fix these and you do need to challenge yourself. This one is very subtle. Acute Charcot, this was missed by an orthopedist. This is actually the base of the first met. There’s actually a fracture that extends. She’s a very brittle diabetic. But you look at this, and you go, there’s really not a whole lot going on with that x-ray and actually there was a lot going on. And look at the gas and the tissue up here. So this was actually had to be addressed. She actually had ended up having an osteo of a second met. We did not have to do anything with that other than open it up. Evacuation, drainage, she went on I.V. antibiotics and then I addressed this almost a year later and back in the days when I was doing a lot of these. Again, I know that she doesn’t really feel a whole lot. So, I’m going to really over met her and make sure I’ve got more metalline and around that area than bone. I would do just the opposite if she was not a neuropath and she had very good structural support because I know her sensation. We keep her off of it and allow her to heal. But I know she’s not going to stay off of it so I really have to hedge my bet in that direction, making sure the medial longitudinal arch is satisfied and you get to the end of this sometimes and you say you wonder if you did any good for them. I will tell you this at the prognosis and the overall outcomes in terms of functionality, pain scores, AOFAS, ACFAS, doesn’t matter what you look at, they’re not very good.
Marie was talking about the worst fracture and the calcaneus being the worst fracture in the foot, agreed. But those are easy. These are the quiet ones that you think you should be doing a better job with them and you think they should have a much better outcome than they ever do and I think that’s where they fool you. We know this, if you take a look at the midfoot and the hindfoot bones, obviously they’re short squad. They’re cancellous bones by their nature and they’re cushioning bones. Their bones meant to absorb force. But if you take a look at the metatarsal bones and that link up and that linkage occurs with that joint and we need to transfer our way from our heel to our midfoot, to our forefoot and then toe off and that link is just a little bit softer. It’s not quite there. I think that’s why these people have pain for a long time afterwards. So these are the tips that I use and just tips for you to take home. I always like to give you guys and anybody I speak to something to take home that I’ve learned, a lot of it the hard way. Making sure that you use some sort of joint distractors if you’re going to do these, really opening those joints. These joints are a lot deeper than you possibly think. You many times will get a half of fusion done. You think you got here, maybe the top two thirds and then you go to compress it and then you wonder why the metatarsal is sitting up in the air. Well, you clearly didn’t get down deep enough. You really need to open these things up. Again, really the final bullet point, which is you really need to exhaust conservative care with these individuals because their prognosis is on the hole, very poor. They typically walk with some sort of a rigid shoe for the rest of their life or some sort of Jones bar or something to allow them to ambulate. So you need to really make them aware of the fact that in these cases where they’re really dusted, they’re probably not going to do great, they may do good. For me, I tell patients if I can get you back to 75, 80%, I consider that 100% given the nature of that injury. Everybody expects an isolated lateral malleolar fracture to do relatively well. I look around the room and I see a lot of head nods and you know, because we’ve all been down the same path together with these patients and they can be infuriating, frustrating and it makes you question whether you should do anything at all with these people other than just put them in some sort of a Skecher Shape-up or shape up or something. Because at the end of the day, do they really do good? So, for the last three minutes here, I would like to thank Dr. Schoenhaus, Dr. Laporta, Dr. Frykeberg and Dr. Kalish, Alan Sherman in the back, everybody affiliated and associated with Superbones. Thank you for having me here. This is a wonderful venue to have in Orlando, especially if you live in the northeast this winter. You know you’re bad when you start going to tanning booths because you’re starting to get rickets. So, this is always a great opportunity for me to meet new individuals, new young doctors, some [indecipherable] [28:03] old veterans and I always learn something from everybody I run into. So, I have two minutes left before the reception. I hear a lot of things clanking out there. So that’s always the sound of a good stuff coming. I appreciate your time, your attention. If you have any questions, I’d be more than happy to answer them otherwise. Safe travels back to wherever you came from and thank you.