Christopher Bromley, DPM discusses the origin of Lisfranc’s naming history, basic anatomy as well as imaging evaluation to make a diagnosis of a Lisfranc joint injury. He also reviews both non-surgical and surgical considerations when dealing with Lisfranc injuries.
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TAPE STARTS – [00:00]
Christopher Bromley: We're going to spend a little bit of time this morning talking about Lisfranc. We're doing great on time reminding you that we're going to scan at the end of the day after the four o'clock hour.
All right, so moving forward, objectives. We're going to take some time to appreciate the origin of the Lisfranc joint, look at the anatomy, review different imaging evaluations. I think yesterday's lecture on imaging, particularly the MRI review that we had from the medical physician that was here was really great. And then, we want to understand what the treatment options are for Lisfranc injury.
Disclosures, I don't have any. This particular lecture is underwritten by a present.
So what is Lisfranc joint? For those of you that have been out of school as long as I have, Lisfranc was named after Jacques Lisfranc who was an OB-GYN and surgeon. And the first description of that particular joint, you know, obviously, involves the articulation between the metatarsals and the arch and this was – it goes back to 1850.
I think that I see more Lisfranc injuries and we're going to talk about trauma. But in my particular practice, I see a lot of patients, I don't know about you, I've seen a lot of patients with that sort of fourth and fifth met cuboid injury than I ever have before and I correlate a lot of that to the shoe gear. You know, so much of the shoe gear that people are wearing now is so flexible and kind of pronates through the midpoint. We're seeing a lot more of that than we see the actual trauma cases, but we'll talk about how to manage that.
So anatomy, there, the midfoot consists of, obviously, all the bones that you're familiar with, the cuboid, the navicular, and the three cuneiforms, and the articulations with the base, and the metatarsal injuries.
Typically, it involved the ligaments, involving the medial cuneiform and the base of the second metatarsal, or third. These are all referred to as sort of Lisfranc ligament. And when I describe them to patients, I typically describe them being slightly thicker than a thin piece of tissue paper so that patients have an idea how easy it is to damage these ligaments and then how important that whole articulation is and, particularly the orientation of the second metatarsal as being the keystone.
So reminding you again this is a CMA lecture so the second metatarsal is key understanding the articulation in the base of the second metatarsal and how it fits into that structure and gives you that sort of keystone structure holding the entire arch together.
Refreshing your memory, understanding from a three-dimensional perspective, obviously, we're always looking at the top. But we have the medial cuneiform and with the relationship of the ligament. So we have the second metatarsal base, the third metatarsal base, and then the red or – is the dorsal ligament and the blue is that interossei with typical Lisfranc ligament that we talked about, and then there's obviously plantar attachments that we need to be aware of, and that would become evident when we look at the other imaging techniques.
Incidents, it's reported 1 in 55,000 US population which is quite common. We have 356 million here in the US. It most commonly involves the first and second metatarsal base and the orientation with the medial cuneiform. About 4% of the professional football players report Lisfranc injury per year and probably the most common misdiagnosis in the foot.
We – when you start looking for Lisfranc injuries in your patients, you'll see more.
The more you look, the more you'll see. It's a, as I said, I think there's a huge relationship to the footwear that is really not supporting and I think the footwear and the use of orthotic will come into how we want to manage it long-term.
So a typical injury that we'll present through your office or through your ED is a high kinetic energy, patients involve in a motor vehicle accident. Maybe they were texting or doing things and then next thing you know, they're involved in a collision, sharp push of the foot against the brake. These are very common in traffic accidents. Also, falls from heights such as industrial accident. There also can be significant crush injuries when things are dropped on the foot.
I just had a patient recently who dropped an anvil on the top of his foot, went to a local orthopedic walk-in clinic, and was given a surgical shoe and came to me with a – it's a pretty significant Lisfranc injury and a second metatarsal displaced fracture and he had a third metatarsal fracture and he had overlying cellulitis. So I was really thrilled to meet him, but he's doing well.
All right. So indirect Lisfranc injury can occur from sudden rotational force applied to the plantar flex foot. So if you look here, this particular player, you can see his – he's in the stirrup, but his foot is in a very, very plantar flex position. And this particular type of rotational injury, very common in riders falling off, also patients if they step into a whole.
I actually have – I played polo for about ten years before I had kids and I've actually done this to myself. My foot did recoil – the best part of the fall was I didn't get stepped on by the horse. It's interesting. Polo ponies are – the last thing they want to do is step on you so you'll be surprised how agile they are.
Other type of athletic injuries that can occur, this is commonly seen in injuries like windsurfing. If you look at this particular windsurfer, he's got his foot in the strap and these straps are snug enough so you can get the forefoot in, but very, very common, windsurfing injury. Also, windsurfing has been replaced now by kitesurfing. Kitesurfer, same thing. And also, snowboarding. A lot of the snowboarders that you'll be treating have gone to a softer boot and the snowboard is particularly dangerous for the foot when the snowboarders are getting on or off the lift because they typically have one foot locked in the board and then they're – and they get tangled up in the – in their snowboard as they're getting on or off the lift. So if you do have an understanding of what's happening in these particularly – in these athletic events, you'll start to look for Lisfranc.
As we've said in the earlier slide, the football players, typically, they're up on the ball, their foot, very large, very athletic individuals so you'll see quite often. Baseball catchers as well, softball. And then, of course, you we do see a lot of ballerinas and dancers that have Lisfranc injury as well.
So again, this is an axial loading to a fixed foot. The force factor is going to push that second metatarsal and stress the dorsal, the Lisfranc ligament and the plantar ligaments allowing that dislocation to occur in the foot based on that load. And you can see when the foot is really not designed to be in this position and when it is and – these puts quite a bit of stress on that.
All right, crush injuries. As I said, they're very more common in the industrial setting. You need to understand the anatomy itself. Mike Caston looked as bad, but it was pretty bad and – when we went into to fix it.
The soft tissue window is always a concern because, obviously, we need to get the ligamentous repair, we need to get the bones back together, and then we have to have something to cover it with, and hopefully enough to cover our fixation, very, very high-risk scenario. There's always a risk of neurovascular compromise because of the orientation of the injury to the structures and as you know, no padding there.
Clinical presentation for the non-trauma cases or like non-crush injuries, midfoot pain, typically, difficulty bearing weight. You'll see swelling across the dorsum of the foot. You'll have – a lot of these injuries that if – they will spontaneously reduce, so you really have to look at them carefully. This plantar ecchymosis is pathognomonic for Lisfranc injury. So if you do have a patient with pain, weight-bearing, and an injury, look for that sign that's going to occur because of that soft tissue disruption.
Also, there's something called the piano sign which is when you're going to push on that second metatarsal head and moving it up and down and you'll have pain approximately at the second metatarsal base.
So what are the various findings? Obviously, this one is pretty obvious. You can see here. But on this particular X-ray, in a typical X-ray that without stress being applied, you don't really appreciate it, but there is an injury here. So you have to, you know, look close. And then, we're going to talk about other – what other modalities you may use to evaluate that.
Again, look for other injuries, you know, not, you know, we can kind of get focused on this because of the swelling, but look for the other injuries that occur. And the case that I was talking to you about my patient who dropped, I was pretty, pretty impressed with – he had a displaced second metatarsal fracture, and a – spontaneously reduced injury here.
But I missed on the X-ray – this is not my picture, but I missed the stress fracture on the third. So just, you know, carefully, you know, don't get pigeonholed and just look at here, look around and make sure you're not missing anything. In a typical finding, you'll see that gap between the base of the first and the second metatarsal. We don't always have the luxury of prior X-rays, but there is a particular injury that we want to look.
All right, again, challenge is the diagnosis. The diagnosis, you need to get a good history, figuring out what they were involved in and then it helps if you appreciate what that particular sport involves. Again, looking for difficulty, we're paying with weight-bearing, swelling of the forefoot or mid-foot, again, the pathognomonic bruising in the arch. Weight-bearing X-rays are very helpful. We do more of that than anybody else so that's something that we do.
Again, unfortunately, a large percentage of the X-rays, if they're non-weight bearing, it will be misread. And then the 85% of the weight-bearing, I think that's how I ended up with a guy, because they weren't really worried about the metatarsal fracture and they didn't really appreciate the Lisfranc's X-ray.
Worst case scenario, obviously we've got normal X-ray and if you have clinical suspicion, go ahead and use advanced imaging. In our practice, we have ultrasound that is surgically attached to me, kind of follows me around from patient to patient. You can use the ultrasound to get an idea of what the ligament structures look like and then going on to order the other imaging techniques.
So again, looking at an AP, look at the orientation of the base of the first metatarsal, it should line up with the lateral aspect of the medial cuneiform. They should be – and then again, a second metatarsal base should line up with that medial cuneiform. So you want to – these are normal orientations and if you see any disruption in that, you want to have a high suspicion.
Moving over to the oblique view, normally, the third metatarsal should line up with the lateral aspect of the cuneiform. And then the fourth, again, the fourth metatarsal base should line up with the cuboid. So those are orientations that you should be aware of as normal findings. And if you see anything that doesn't line up and you have pain and swelling, go on to do the further imaging.
Again, this shows you that this is the same foot in a non-weight bearing X-ray compared to a weight-bearing X-ray and I think that's why most of our urgent cares and those walking orthopedic clinics missed this, is because they don't typically do weight-bearing X-rays.
Again, further imaging, this particular, you're looking at a T2 image, T2 MRI of the foot. You can see significant mirror reaction in this particular and you can see a disruption here in the ligament structure and the orientation that we were talking about between the base of the second metatarsal and that medial cuneiform.
Other imaging, you can see on this T1 image, you can see a disruption between that Lisfranc's ligament and the base of the cuneiform.
CT is also very helpful when it comes to surgical planning. Without CT, you would really not appreciate how disrupted this particular structure is. And it gives you orientation and reference to your surgical planning for the correction that you're hoping to get.
We did have a talk yesterday about using 3D CT scans. I don't have those available in a… Dr. Kailash's office is a little far from me to send them to. But I do think if you have access to a 3D CT scan, I think that's very helpful for surgical planning and also educating your patients as to the severity of this injury.
One of the things you should always do is when you're talking about this particular injury to a patient is have them appreciate, you know, what a difficult injury this is to heal, that they should expect that the rest of their life will involve pain and that you will do the best you can to give them a good outcome. But they need to understand that this is never going to be the same again.
As I mentioned earlier, ultrasound is a very valuable tool in my practice. If you look at this particular ultrasound, you can see the relationship between the second metatarsal base and the first cuneiform, you can evaluate that dorsal ligament structure. When you're looking at ultrasound, the way I describe it to patients is white and grey is good, black is bad. So if we see a hypoechoic change, whether you're looking at a plantar fascia to the – help them with their plantar fascias so you're looking at this particular structure.
Again, the relationship between the first cuneiform, the distance, you know, greater than 2.5 millimeters is indicative of a Lisfranc's ligament tear. Now everybody's different, every patient's a little different, but again, being able to use the ultrasound to appreciate that. Again, note that the dorsal arrow – the characteristic to get the bone contour and the ligament at the arrowhead. Okay.
Ultrasound, again you can see this one it's pretty blown out, very swollen. It's again a very helpful tool. It measures about 2.3, and when it's that wide, it's pretty indicative that normal measurement is as very small.
Here's some other ultrasound, this is showing a 25-year-old who had the relationship between the significant swelling. And then, one of the things you can do, depending on your ultrasound is you can add color to your ultrasound and that can give you an appreciation in these acute injuries of what that Doppler will show you, the blood vessel and the leakage into that area.
And so that you can again, appreciate that gapping between them.
There are classifications. I really think classifications are very helpful for passing your boards, but they don't really do much for day-to-day practice obviously. Whatever's broke, we're going to fix. But to be complete as far, we got the Hardcastle, and Myerson Classification shows you total incongruity and the relationship is lost here.
Again, we have partial incongruity, only involving the first and then here we have the obviously, the lateral metatarsals involved and then displaying here in a divergent pattern here. Again, these are very, very difficult to control and obviously, a very complicated repair.
There is also the Nunley and Vertullo Classification. This is a little bit more specific in reference to the relationship of the ligaments and the gapping as we talked. You know, that 2.5 millimeter diastasis is hallmark for loss of the injury or rupture of the dorsal and then typically the Lisfranc's ligament here. We've got stage one is just a sprain, stage two, we've got the ruptured Lisfranc, and then at stage three, we have a significant displacement. And if you evaluate the position of the second metatarsal base, that's involved as well.
Again Quenu and Kuss Classification can be osseous, the ligament is combined. Again, we're seeing that this really focuses on the direction of injury and was a much older classification, a little bit simpler.
All right, so the key to success is accurate diagnosis.
We've established that, weight-bearing s-rays are key, ultrasound is very helpful. If you think that there's suspicion and you don't have a big enough gap, go ahead and get your MRI. If you're going to be planning surgery, I highly recommend that you get a CT scan so that you can really evaluate the whole foot in reference to your repair.
Non-operative, again, very important, you know, to immobilize these patients so that you can control their pain and give them an opportunity. If they have a ligamentous injury, that is possible to manage. If we've got no significant separation, we can manage these patients. Typically non-weight bearing for 4 to 6 weeks and then weight-bearing in the cam boot, and I don't take them out of the cam boot until they're pain free with weight-bearing in the cam boot.
At the same time, we'll do early intervention, PT, range of motions, so that we don't lose the foot. And then I think it's very important to progress these patients, get the orthotic ready for them, do the orthotic scanning and planning, while they're still immobilized so that you can have the orthotic ready for them.
And I think that the other part of that is making sure that you talk to them about shoe gear. You know, do – spend a few minutes looking at the shoe gear. If you've got a shoe that's really flexible, they have to understand that that's not going to be something that they can wear. Spend time, you know, demonstrating, referring them out to get the right shoe, combining that with your orthotic.
Also the biologics are helpful and we have access now to the allografts. We use the amniotic fluid, we used to just be able to get cryopreserve, now we have at room temp and we can use this to supplement. It's not first line, but if you've got an injury that's not healing, I would highly recommend you use the – a biologic injection as opposed to cortisone. Because as we've talked about this morning, cortisone's not going to do anything good for your patient, it will atrophy the tissue worse, and eventually make their condition worse, the more cortisone shots they get.
If you have a patient that you have to take to the operating room, obviously the operative approach, classic, is two approach. You've got a medial and lateral incision. Very important as you plan this, your medial incision, first, will be medial to the EHL and you want to make from the navicular all out to the mid-shaft of the metatarsal.
Again, you're not going to be able to do this through a very small incision. You need nice, long incisions, good dissections, so that you're protecting the DP and the deep perineal nerve. Very important that you retract them and that you're aware of where they are. And again, if you're involved in the second metatarsal base, you've got to watch out for that perforating artery that we have going from dorsal to plantar. The lateral incision, again, is going to be sort of between the base of the third and fourth metatarsal.
Just a reminder of how complicated the vascular structure is here, you've got to be aware of that DP as we talked about, as well as the dorsal venous arch so that you're involved and also the deep perineal nerve. And then on the lateral approach, we want to watch out for those other superficial nerves as well. Again, big incisions so that you can really appreciate the relationship between the first metatarsal and the second so that you can get in there and do a good correction.
So again, this a very difficult deformity to correct. This is an older X-ray but at that time, that's what we had available. Again, we've got dissection down doing good soft tissue release so that you can fully evaluate the TMT. We're going to do – again, attempt to get arthrodesis between the metatarsal and the cuneiform so that we've got a good, stable construct. We can't rely on the ligament for that structure any longer.
Again, the second incision is going to be from the cuboid out to the third. Again, we want to protect the superficial perineal, and we want to try to get everybody back where they were. There are lots of different fixational turners out there, lots of contoured plates, different companies are available.
The advantage to them is that they are contoured, they've got locking constructs, they're small, they're flexible, they're easy to use. The downside is that most of them will need to come out because there's no soft tissue covering these and it's going to be very painful for sure here down the road. So whatever one you particularly like, feel free.
All right, so there are some external fixators out there. This is showing sort of an external rail. And in combination, I don't think this particular correction went that well, but it was a good attempt. Again, mini-foot crush, these are long-term fixation. Typically within about six months, hard wire will need to be removed. Ex-fix is popular and some surgeon's hands is not in mind, but it is an available option in combination with screw and plate fixation.
This is an interesting article from Journal of Foot and Ankle, with a talk about management of complex midfoot fractures with ex-fix. The interesting thing was there were 11 patients in the study, and pretty much everybody had complications in morbidity afterwards. All of them had pain, you know, so even though ex-fix is a very effective technique, you know, anytime we get in involved in here, it's pretty complicated.
So there's a newer fixation now. There's a company in the Northeast that makes a small device that can be used in the wrist, as well as the foot. Basically, it's a small saucer, and then you can apply the screws to the – you sort of stabilize this.
The advantage of this particular system is that you sort of cone out and you make a little place for this to sit and then it's not very proud. So for a woman, or somebody who you might be worried about pressure or the fixation, that's a very effective as well. But it would need to be done in – with other forms of fixation so you got some stability of the first radial medial column.
Mini TightRope is obviously for ligamentous injury, particularly Lisfranc ligaments is still a very effective technique for those injuries that you don't need to form an arthrodesis. There's different directions. This is obviously stabilizing, the medial column to the second, more commonly with the previous X-ray.
Now, from a post-op management perspective, it's again, really important to remember and educate the patient that they're going to be non-weight bearing for at least 6 weeks, and then at least 4 to 6 weeks weight-bearing in a cam boot. As I said before, in reference to the non-operative cases, you definitely want to plan ahead so you'll have an orthotic or brace ready for these patients when they get to weight-bearing because this is a very, again, very difficult recovery. So in my hands, we, you know, using – having an AFO, even an Arizona which is a really great device, or a modified Colorado, it's a really great device to kind of wrap around and have the patient understand that they're going to wear this for a year. This is a year-long recovery and that, you know, you don't want to stress your fixation anymore than you need to, having them understand that they will progress typically from an AFO to an orthotic and this is something that they are going to have deal with long-term.
Complications, obviously, very common in this particular type of surgery.
You can lose your correction. You can have incomplete reduction as we saw in some of those other X-rays. Post traumatic arthropathy is very, very common and you can end up with compartment syndrome for these injuries. You can have neurovascular injury from your surgical technique or from the original injury. And then like the case I told you, I got all of the above including an infection. So it is a very, very difficult.
My particular approach is if you got a crush injury with a big soft tissue, and you got an infection, you've got to manage the infection. You've got to manage to the soft tissue, making sure that you don't have a compartment syndrome, and then once you get it stable, then you can go in and fix the defects.
TAPE ENDS - [26:50]