TAPE STARTS – [00:00]


Michael Troiano: Okay. So, we’re going to change gears a little bit to Lisfranc’s Injuries. Again, my name is Michael Troiano. I’m from University of Pennsylvania Presbyterian Hospital at Philadelphia.

Lisfranc’s – Jacques Lisfranc was a surgeon in the Napoleonic war who noticed forefoot gangrene in equestrian riders. So, basically the idea would be the soldier would mount the horse, the horse would be spooked or what have you and he noticed time after time, if the foot was in the holster of the horse and the horse took off just right, it would kind of break the mid foot right across. And a lot of these people went on to gangrenous changes, amputations, obviously. If you’re looking into the 1800s, a lot of these people did not live.

So, it’s actually Del Sel in 1955 that connected the injury – the dislocation injury. Because everyone thinks that Lisfranc is responsible for naming the injury. He’s actually responsible for naming the gangrenous changes. But nonetheless, Lisfranc’s joint injury includes a broad spectrum of injuries ranging from sprain or subluxation to growths, fracture, dislocation. All of those are used, you know, broadly for the Lisfranc’s injury.

Now, Lisfranc’s injuries are one of 55,000 injuries a year, 0.2% of all fractures but not a tom. However, 20% of them are thought to be misdiagnosed or undiagnosed. They are more common in males and in the third decades or 20 years old, you know, 20 to 30 years old. They account for more than 15% of all athletic injuries. So, this is something that I think in my own practice I see missed a fair amount. And a lot of it can be gleaned just by listening to history.

[1:59]

So Lisfranc’s injury is the person who shows up after a car accident, you know, my foot’s been killing me and they kind of have this diffused pain across the mid foot region of the toes. And they often times can’t remember any direct trauma or what have you because maybe they bang their head at the same time or what have you.

But what you see often times is you see a patient who sitting in the light or who’s driving their vehicle and they get into a car accident and the anti-lock brakes push backwards on the foot which is pushing down on the brake. And the anti-lock brake and the snow – that in Chicago, you know, kind of stops you from going and sliding actually pushes back and induces a Lisfranc’s injury.

Obviously, you also see it in football injuries, soccer injuries, gymnasts – gymnastic injuries. 4% of college football players, more so offensive line men sustain a Lisfranc’s injury every year and it’s increasing. The sports related incidents of Lisfranc’s injuries are certainly increasing. Especially if you have a high sports practice, a lot of soccer players wearing thinner cleats. They like to kind of feel the ground, feel the ball. And unfortunately, a lot of embedded cleats with twisting injuries lead to Lisfranc’s injuries.

Now, I’m not talking about the fracture of Lisfranc’s because obviously those are, you know, easily told. It’s the sprain and strain that are the more difficult to diagnose and the ones that have the longer sequela if you don’t diagnose them appropriately.

Lisfranc’s joint complex is inherently stable with little motion due to the stable osseous architecture of ligamentous restraint. Interestingly, if you’re going to divide the Lisfranc’s joint up, you should divide it into three different parts.

Now, the red part here, the lateral portion which is the cuboid in metatarsal 4 and 5 are actually responsible for being the most mobile and are the shock absorbers. So when you think about it, when that foot steps down, these are the first to kind of collapse. If you – if you hit with an inverted foot on the calcaneus, when the lateral foot hits the ground, that – the fourth and fifth metatarsals will usually kind of pop up very slowly to allow the medial column to get down.

[4:15]

Now, next, the medial column hits the ground and then everything starts to get ready for propulsion and tow off after. And that’s where we see the blue portion metatarsals 2, 3, and cuneiform 2 and 3, intermediate and lateral become the more rigid ones. And they act as a lever arm during propulsion which is pretty interesting, because if you think back to pathomechanics as Jarrod said, the peroneus longus inserted unto cuneiform 1 in the base of metatarsal 1 here, it really is what we think of makes that rigid lever and propels the person. And it certainly does, but it also has attachments to the mid foot here. So, these are inherently stable. The keystone of the foot and now peroneus longus makes the medial column tight as well and then all three of these working constant to propel the person forward.

If we look at just the design. It’s a brilliant design. The second metatarsal’s recess proximally relatively remainder of the tarsal, metatarsal articulations and it’s more disconfiguration, right? So, it’s the second place on the foot and ankle that we really see more as the first being the ankle.

Obviously, a mortise joint is a hinge joint, except for there’s no hinging involved in the Lisfranc’s joint. Lisfranc’s and that – and that mortise joint act as keystone here within the transverse arch or otherwise known as Roman arch. The shorter length of the second metatarsals, as well as decrease depth of the TMT mortise, allows increase risk factors for Lisfranc’s injury because of that shortness.

Now, so often times we think of the Lisfranc’s joint ligament right here on top, but it is not on top. In fact, look at the ligaments, there’s only 7 dorsal Lisfranc’s ligament, right?

[6:06]

7 dorsal, tarsal, metatarsal ligaments. The line shared with them are plantarly and as tough as those are, nothing surpasses or even touches the strength of the Lisfranc’s ligament.

Lisfranc’s ligament is literally intra-osseous. It’s between the two bones. And therefore, because it’s so tightly embedded between those bones, it’s a very tight and broad ligament.

I like to think of the Lisfranc’s ligament as a rubber band, okay? So many times, you know, we do so much in medicine whereby it’s – cover your butt, right? So someone comes in and you suspect that they have a Lisfranc’s injury, you treat them appropriately in a cast and CAM walker and they still won’t get better and then you have a couple injections and they’re still not better and you order an MRI somewhere along the line and the MRI shows Lisfranc’s joint ligament intact, right?

But clinically, clinical examination obviously, it’s king. Well, how can you go ahead and treat this person surgically with no objective physical tests besides physical examination? Are you now going to take this person to the operating room, throw a screw across the Lisfranc’s joint and then, you know, something bad happens, your case gets reviewed and they turn around and say you had no business doing a surgery in the first place, because the MRI shows the Lisfranc’s ligament intact?

So, that’s something that kind of keeps me up at night, but I’ve made my peace with it to think that this Lisfranc’s ligament is like a rubber band, okay? So, the rubber band can stretch pass the point of elasticity and snap into two pieces. That’s the only time you’re really going to see it on an MRI.

Also recognize that MRIs usually have cuts that are about 3 to 5 millimeters, so half a centimeter. So, if the cut is just not perfect, you’re going to cut right over that ligament and miss it pathologically on your MRI. Some of the better units that are foot and ankle dedicated in major universities, you can get 1 or 2 millimeter cuts but they’re few and far between.

[8:03]

So, the other way that you have to think of the Lisfranc’s ligament is in addition to snapping into two pieces, it can actually go past it’s point of recoil and then still be intact. In other words, just like that elastic band, you can take an elastic band and stretch it out and it doesn’t recoil but it’s still intact, just not in the presence of which it started – it’s native state. And that’s what ends up happening with the Lisfranc’s ligament when there’s a sprain and it doesn’t recoil, you order the MRI and the MRI shows the Lisfranc’s ligament intact.

So, rest assured, MRI, although isn’t adjuvant and isn’t aid in making the diagnosis by all – it stretches the imagination, physical examination is king.

Now, the TMT joint is stabilized by insertions of the tibialis anterior and the peroneus longus, the TA can become entrapped between the cuneiforms as well. So, this is where your ultrasounds help you. If you have a good ultrasonographer that can really go in there, the tibialis anterior, where it comes down obviously, peroneus longus is coming through the plantar aspect of the foot to insert here, the tibialis, the anterior coming down, inserting largely on the medial cuneiform but there can be some branches that insert into the Lisfranc’s joint keeping it open.

Then, of course, in the acute sense, you have to be cognizant, deep perineal artery divide between the first and second metatarsal basis and it can be avulsed or torn in more severe injury pattern. So you can have nonstop pumping blood into this area, thus, setting the sentence for compartment syndrome.

So, Lisfranc’s injury acutely, you want to think in your mind compartment syndrome, chronically without any real objectifying means on examinations – MRI examination. You have to think maybe sprain, not completely torn and of course, there’s mid portions as well.

So mechanism of injury. This is with or without fracture characterized by disruption between the articulation of the medial cuneiform and the base of the second metatarsal.

[10:08]

These can be mild sprains to sever dislocations and fortunately or unfortunately, I’ve seen those with horrible dislocations, status post ORIF do great. And I have seen people with sprains that, you’re like how can this even bother you and they’re miserable. So, the degree of the injury doesn’t necessarily correspond to the amount of pathology or symptomology the patient will have.

This can be a direct or indirect injury. Indirect is much more common. Direct for supply to the Lisfranc’s associated with multiple atypical tarsal fractures, vascular compromise, and compartment syndrome. Indirect are rotational forces, right? It’s the football player who plants and cuts the tailback, who gets tackled when they – when someone falls on him, fall from a great height. But again, low energy as well. Like, falls from a lower height, soccer injury, even planting a left foot to kick the right foot as the right foot comes through, one can, you know, twist the Lisfranc’s injury on the left foot as is the plantar or pivot foot.

Physical examination, obviously, this is the acute sensor. You’re going to see this battle sign, this black and blue on the bottom of the foot, inability to bear weight, tenderness over the tarsal and metatarsal joint with always a suspicion of compartment syndrome until proven otherwise.

This is something that the threshold to put a wick’s catheter in, should be very low because guess what? This shit hurts, alright? So, that person’s there and they’re in a ton of pain and I’m not going to take my chance. What’s normal pain, what’s Lisfranc’s pain, what’s compartment syndrome pain, they’re already in pain – stick a wick’s catheter in or strike a catheter and measure the compartments, put yourself to sleep that night knowing that they do or do not have compartment syndrome and you treated appropriately but did not miss it.

Now, physical examination. There’s two maneuvers to stress the joint. The first, was described by Curtis.

[12:00]

You stabilize the rear foot and you apply abductory and supinatory forces to the lateral fifth metatarsal and then an abductory and pronatory force to the first base. And what that allows, it allows stressing the ligaments. In a fracture, you’re going to see opening up like we see in the top two pictures. In just a strain or assuming just a sprain, you’re going to see nothing but they will have pain on palpation of that area.

Then, the one that I prefer is the piano key test. Well, literally what you’re doing is you’re taking your fingers and you’re pushing down like a piano key and then you can push up like a piano key. I usually stabilize the forefoot when I do this and then of course, there’s distasis pain as well. You take the first metatarsal, the second metatarsal, and you squeeze them apart and the person jumps through the roof because they have pain back at the cuneiform joint number one and two. So these are your three big physical examination findings. And of course, swelling and a lot of it is history.

Exercise can be of pretty limited value in a sprain. They’re fantastic for a fracture but of course, you want to take the contra-lateral side at all times. Metatarsal base should line up with corresponding cuneiforms and cuboid. Any gap more than 2 millimeters is significant. The flex sign is obviously the avulsion of the Lisfranc’s ligament off of the second metatarsal which you can kind of see in the interspace hanging out there.

If you are planning surgical intervention, alright, the call off for surgical intervention is usually 2 millimeters or greater. So, 1 or 2 millimeters, you don’t usually operate too acutely. Two millimeters or greater, you do. The best way to quantify that 2 millimeters or greater is a CT scan but not just any CT scan, a weight bearing CT scan is essential.

So I can’t tell you how many times I’ve sent a patient for a weight bearing CT scan. It’s called a pedCAT and a person goes for the pedCAT, they come back with a regular CT scan and that’s like totally a waste of money because it’s not going to do you any good.

[14:04]

And on top of that, you know, it’s a waste of radiation because, what do I say, it’s like – a CT scan is like 15 chest x-rays or something like that, the amount of radiation that you get. So, it’s, you know, you have to be clear to that patient weight bearing CT scan, put it right on the script. Do not do the CT scan if you cannot do weight bearing. That’s what I do now. Almost inflammatory when I order them but the worst thing is to send someone for a test and come back with useless results and a high co-payment.

Again, you can order the MRI to rule out purely ligamentous injury. Bone scan will look at the bruising of the joint but will not assess the ligament. So, you’ll see activity on the bone scan that you can then deduce if not for the injury would the bone scan not be hot and therefore, you can deduce the middle which is Lisfranc’s ligament is damaged. But you’re not going to get a positive finding from a radiologist saying, consistent with Lisfranc’s injury. You’ll just see uptake in the area consistent with an acute injury.

So, radiographic findings, again, gaping greater than 2 millimeters, the bone fragment sometimes on the lateral view. Often times, you can see dorsal subluxations of the metatarsals at the TMT joints and most importantly less – greater than 15 degrees of tarsal – of talar-metatarsal angle. So when you come down here – here’s your talar-metatarsal angle and you can see this literally belongs down here.

Now, here’s a decision tree for Lisfranc’s injury. Non-weight bearing radiograph is normal, okay? Then always go to a weight bearing radiograph. And that’s why these people are coming to the emergency room non-weight bearing is what the ER always gets unless they consult the podiatry resident – orthopedic resident. You want to make sure that person’s weight bearing from the jump, save yourself some time. The non-weight bearing radiograph will simply show if they have fractures or not which, you know, usually can pretty much tell before the radiograph’s even done, if they have fractures or not.

[16:03]

Now, after weight bearing radiograph, if you have a high suspicion, then you want to go down the MRI route to look at ligamentous tears, sprain, or occult fracture. If you do have a fracture, go down the CT route because you need to decide if you’re going to fix it or not and that’s where you measure your 2 to 3 millimeters. And if you have a normal x-ray with a low suspicion, treat it like a Lisfranc’s injury anyways, with a booter what have you because again, these injuries can take several months to heal on their own.

Classification system, we’re not going to spend a ton of time but they’re basically the Qeunu, Kuss, and Hardcastle and Myerson classifications are the most accepted. You certainly need to know them more for your residency interview then, your boards. But just recognize homolateral, isolateral, and divergent are the different types and the more joints disrupted the more severe and increased long term sequelae.

So, this is a study, not a huge patient population. Fifteen athletes looking at mid foot sprains and the findings were, stage 1 and stage 2 with 3. So, stage 1 was nine displaced with non-operative treatment. Stage 2 and 3 had diastasis without arch height and with arch height, respectively. All of them were treated with anatomic fixation and reduction.

So if you have a stage 1 and you immobilize, the results are just as good as if you have a stage 2 or 3 and undergo the surgical intervention. So, again, stage 1, you’re looking conservative therapy until it proves otherwise, right?

There will come a period of time where this person, no matter how much of an even up-brace you put them in, and the CAM walker on the other side or what have you, they’re 1 month, 2 months, 3 months, 4 – by 6 months if they’re not better, try a couple injections. And then, if they’re still not better and they’ve tried therapy, move on. Just throw a screw across the darn thing.

[18:04]

Conservative treatment, again, is cast immobilization or protective weight bearing in a CAM boot for about 4 to 6 weeks. And really, is indicated for no displacement whatsoever. If there is a fracture and there is 2 millimeters of displacement, people do much better with a surgical fix than conservative therapy.

Diabetics also, I will tell you that, where’s the number one place for a diabetic to get Charcot? Lisfranc’s joint, good. So, Lisfranc’s joint, why? Because the equinus of the – God bless you – the equinus of the Achilles basically dumps all that weight unto the Lisfranc’s joint. So, if someone has an occult Lisfranc’s injury for, you know, and they’re diabetic and their A1C is a little high, and their protective sensation is not great, you absolutely, absolutely can guarantee that they’re going to get Charcot there within the next year. It just happens. There’s fault of the joint. There’s pre-existing trauma to the joint and the presence of their likely equinus and the presence of their, you know, neuro-traumatic injury and, boom, they end up with Charcot. So, these are the people, again, you really want to protect. Weight bear for 4 to 6 months, even consider bracing afterwards.

General surgical considerations are only emergent in this case for compartment syndrome. Compartment syndrome is the only emergency that you’re going to address the Lisfranc’s back. If you have a fractured dislocation, wait till the wrinkle test occurs. Swelling takes about 2 to 3 weeks. It’s what gives you a good long while to get your CT scan and really plan your equipment.

Now, how are you going to fix this? Incision plan is going to depend on what’s dislocated. So, normally, my incision, I use these two. I very rarely use this guy because often times, you know, the fourth, fifth metatarsal cuboid joint can be pinned percutaneously and you don’t often times need that incision unless there’s a big crush fracture of the cuboid or unless there’s a huge dislocation.

[20:01]

Also, some people advocate that the third – advocated the third incision can be used to put a clamp there.

Also, consider your Rule of 7, right? Skin bridges. It doesn’t take much for these guys to necrose, which is why again you want to wait until all your swelling is really gone because the worst thing happens is a fracture. It’s even more bad if we need a skin graft over this area and you obliterate all the – you obliterate all the neurovascular structures because they all necrose. So certainly, this is one that you want to plan 2 or 3 weeks out, go for multiple skin checks, make sure there’s no blisters, and do not operate until the swelling is virtually non-existent.

Certain fracture patterns may cause impaction of the cuboid. You’re likely going to see this on a CT examination. I will tell you that this is a super gray area for CTs. What is it? Is it a foot CT or an ankle CT? It depends where you are. So, you know, if a patient comes from faraway and I’m sending them to an imaging center, I certainly called the imaging center and say, “Look, I want to look at the Lisfranc’s joint.” Is that going to be best seen on foot or ankle CT? Because often times, the ankle CT in some people stops here and you get no midfoot and the foot CT will often times stop here and you’ll get no cuboid, so something to consider.

Again, obtain contralateral foot radiographs. The purpose for that is because I cannot tell you how many times somebody, you think, has a – has an injury that, you know, on one side and then you look at the other side and their Lisfranc’s joint is wide open on the other side too and it’s a normal anatomic variant.

So again, I’ve said this about 30 times, obviously, it’s important. 2 millimeters of shift. You’re looking at ORIF. Bony dislocations, you’re looking at ORIF. Now, primary arthrodesis is one of the things that I favor much more than ORIF.

[22:01]

When I say ORIF, I – most of the time, mean, primary arthrodesis. Why? This is a tightly woven joint anyways. So when I was out of my residency and fellowship, there’s a huge push to do ORIF.

Now this, on many levels, makes zero sense to me. It goes against everything that I was ever taught. Why? Well, usually, you like to go from stable to unstable with your fixation. That’s not happening here, okay? Stable to unstable is happening here. Excuse me, unstable – stable is happening here and here, but not here. So that’s kind of weird for me.

Secondly, why put a screw across a non-prepared joint? All it’s going to do is destroy the articular surface and you’re going to create a post-traumatic arthritis. So I don’t love ORIF at any capacity unless it’s just with K-wires and it’s not a significant dislocation that I anticipate is going to tighten up over time with the ligamentous structures and everything is going to be fine. So I save this for the isolateral dislocation or when everything goes one way, the homolateral, I don’t really favor this for fraction too – fracture too much.

If the foot is displaced grossly, you put it back on, you throw your pins, the soft tissue structures tighten up, and hopefully, everything is hunky dory after that. But if there’s comminution, if there’s fractures, I’m looking primarily at a fusion were joint-spanning techniques.

Now, again, I made the statement going from unstable to stable, well, this is your unstable to stable screw from medial cuneiforms to the second metatarsal. So the thinking is, the strongest orientation for Lisfranc screw should be from stable to unstable, from here – actually from unstable to stable, so this location. And that is the non-traditional way of throwing a screw. In actuality, study done – actually, the mean is pretty good here.

[24:00]

Excuse me. It is not great here, but the results are pretty even that the strongest screw throw is equal. In other words, it doesn’t matter if the screw goes from here to here or from here to here, second cuneiform to first – I mean, second metatarsal to first, or first cuneiform to second metatarsal, the results are exactly the same.

So now, when I throw these screws, what I do is the first thing I do is I make an incision in here in the second interspace, make my incision, find the base of the second metatarsal, and then what I’ll take is a screw, a cannulated screw, and I will throw the screw from the second metatarsal to the cuneiform because this is a lot easier to start at than it is to end that and this is a lot easier to end that. You have a wide surface here so that if my K-wire comes out here, I’m okay with it. If it comes out here, I’m okay with it. If it comes out here, I’m okay with it, but I need the starting point to be the second metatarsal, right?

So as the K-wire comes out, now, I throw the K-wire until I can just see the tip of the K-wire. So I’m throwing the K-wire out immediately. Now, I make my incision and put my measuring guide here and now, I have an accurate measurement. But it doesn’t stop there. You now take your K-wire and you push it all the way back through and grab it here or halfway through and grab it with a mosquito.

Now, I have a Shish kebab of K-wire from one side to the other and I’ve measured the distance of it. Once I’ve measured the distance of it, the rest is cake. You’re going to pass your underdrill across, countersink here the cuneiform, and then, you know, little poke with an overdrill, and then you put your screw in.

The good part is these screws used to be crap, all right? They were cannulated screws and they break. Now, there’s manufacturers – this is not a Stryker-sponsored lecture, but like the one that I used, Stryker actually has a Lisfranc set that their cannulated screw is just as strong as a non-cannulated screw. So solid screw and a cannulated screw – obviously, the cannulated screw is a lot easier to use and at the same strength as opposed to your old-fashioned, you know, fully threaded solid screw.

[26:06]

So it’s a nice little advent of medicine and it makes it a lot easier for you. It saves your time.

So this is another study. Biomechanical comparison of dorsal plate and transarticular screw fixation. So here on the right, this is ORIF with your screws and what you can see is boy, the – destroyed these articular surfaces, right? You are inciting arthritis here. And guess what? This is going to continue to die. Why? Because you’re taking this big screw head and you’re pulling the two metatarsals together, so you’re going to cause pressure necrosis.

Dorsal plate is a better way to do this. There’s articular – transarticular fixation, leads to an additional damage of the articular surface between 2% and 6%. But dorsal plate, these are coming out. Unless you have a big bulky man or woman that really don’t care too much about what shoe they’re wearing, I don’t care how thin your plate is or how tightly those screws locked down that’s coming out at some point. People can feel that. But the good news is once it comes out, you’re done. You don’t have to worry about any long-term sequelae that you’ve created unless you irritate the nerve obviously.

Here’s more bridge plating, temporary bridging with locking plates in Lisfranc’s injuries, studies of 34 patients. The conclusion, bridge plating and transarticular screw fixation have comparable outcomes.

Okay, so primary arthrodesis is probably what I favor. Why? Well, again, there’s not a lot of play in these joints anyways to begin with. Remember, it takes a significant force to create a Lisfranc’s injury, a car accident, football injury, what have you. Why? Because that joint is so tightly woven together, both by the 30-something plantar ligamentous structures and the 7 dorsal structures and the – in the Lisfranc’s, interosseous ligament, and then the keystone and the way it’s shaped to begin with, this is a hugely stable joint. So this is one that’s most tolerant to fusion if you can get fusion to occur.

[28:02]

So you’re going to come in, take of all the articular surfaces, I usually use a burr and hit this little spot up here, and then you just go ahead with screws or plates or staple – I love staples. They make it nice and easy and the likelihood that you’re going to require another surgery after fusion takes place is again, only for hardware removal and not for non-unions, so case and point.

Let’s just say we do an ORIF. One procedure, do the ORIF, right? Person’s miserable. Oh, they’re miserable because of the hardware. Take the hardware out. The second procedure, still miserable. Oh, well they weren’t miserable because of the hardware, they’re miserable because they had a non-union or post traumatic arthritis. Now, we’re going to go back in the third time. What are we doing? Now, we’re fusing it except we’re going to go back in a fourth time because now the hardware’s prominent again. So this person, is probably going to trust you for the first two surgeries, by the third or the fourth, they’re going someplace else. It’s better to just get it done with. It’s great if you have rent to pay because it’s four surgeries as opposed to two though. So it’s good practice management to do four, right?

Surgical constructs, there are multiple. The striker has come up with the anchorage plate. This is kind of Lisfranc plate that holds everything together. There’s offset in place, a few synthesis come out with offsetting, locking plates, Arthrex has a cannulated system. There’s a myriad of plates because again, the more and more apparent this injury is getting, the more common it’s getting, the more and more people active in contact sports and the diagnosing of the injury. The manufacturers have responded appropriately.

For those residents in the room, there’s some landmark articles that you should read. I challenge you to read them when you leave here. Number one is a study 2006 JBJS, American version treatment of primary ligamentous Lisfranc’s joint injuries: primary arthrodesis compared with open reduction internal fixation. What you will find is primary arthrodesis of the medial two or three races.

[30:00]

A better short and medium term outcome compared to ORIF for those four surgery reasons which are practical and understandable versus the two that we talked about earlier.

Another landmark article, Foot and Ankle International 2009, Open Reduction Internal Fixation versus primary arthrodesis prospective randomized study of 40 patients. This one identifies no statistical significance in functional outcomes, but again, we have to be cognizant of a patient that doesn’t have a successful ORIF.

Finally, what’s new? Arthrodesis versus ORIF for Lisfranc’s fractures, orthopedics 2012 shows this is just a systematic review of qualitative literature, literature review and shows both procedures yield satisfactory and equivalent results through a slight – though a slight disadvantage may exist in performing primary arthrodesis in terms of clinical outcomes.

So again, my take, my experience favors this which is primary arthrodesis, internal fixation, low energy Lisfranc’s injury, the primary arthrodesis group returns faster to full duty at an average of four and a half months with implant removal higher 83% in the ORIF group. And then often times, implant removal does not solve your problem which is why they require an arthrodesis anyways.

Active duty military population studies go on and on and on. Study after study after study either shows that primary arthrodesis is the better choice or equal choice to ORIF with less risk. So I challenge you to read these.

Finally, I want to spend a second bioabsorbable screws. There is a foot and ankle orthopedist in Philadelphia. His name is Steven Raikin. He has been paramount in looking at these bioabsorbable screws. The idea is to put the screw across and then there’s no need to remove the screw because it’s absorbable.

A study of 15 athletes, 3.5 millimeter bioabsorbable poly, the AOFAS score is 35 pre op, 92.7 post op.

[32:08]

The conclusion, bioabsorbable screws appear sufficient for treating Lisfranc’s diastasis but do not necessarily obviate or make unnecessary fixation removal.

Joint-sparing fixation again, this came out. This is an Arthrex kind of tight rope end of button, tried it a few times. I personally didn’t have great results, some of my colleagues had fantastic results but with transarticular screws, there’s a concern for increased rate of posttraumatic arthritis and the idea is to avoid those joints as much as possible. My feeling is consistent with this disadvantage suit your button techniques may not adequately control multi player – planer instability patterns and obviously multi planar instabilities how these occur in the first place. Again, these are not just a boo-boo, this is someone in a car accident is kind of contorted, football player who gets twisted up that, type of thing.

Dorsal bridge plating, transarticular screws, obviously a avoid the joints. Results are great if you’re – if you’re off the camp of ORIF versus primary arthrodesis, however guarantee this hardware is coming out at some point.

Plantar approach. This is one of the newer technologies, plantar approach. The idea is, we all know the stress side of the metatarsal is the plantar side – so you want to plate the plantar metatarsal, right? Downside here is you’re taking out a lot of soft tissue. In particular, the peroneus longus insertion site and then of course as you get across the mid foot, boy, there’s some structures there that you don’t want to go plantarly for, much like the nerves and arteries, right?

These are a couple my cases. We’re not going to spend a ton of time because we’re a little over but there’s a young man, 20-year-old, he was treated for 6 months ad nauseam.

[34:00]

First, we started with – he was a trash truck driver, twisted his foot getting down on the trash truck. Twists is Lisfranc’s joint up, imaging didn’t really show much. He was immobilized ad nauseam again 6 months in a boot until his hip started to hurt. One singles screw, three weeks post op, he’s fine. You know, it’s been several months now and he continue to be fine. You do have to sometimes remove the screw but if you do, it’s an easy fix.

This is a woman, 24 years old who was involved in a car accident. Dislocation, she had another surgery by another’s surgeon. Put a screw across which ultimately broke, I did not know she was painful because of the broken hardware or because of the injury itself. So I took the hardware out. Told her, we’ll see how you do which is here. She ultimately still had pain, so we went forward with the fusion. This is the construct that I prefer down here. This is a striker plate with a – going across their lapidus plate with multiple staples just kind of peppered across each joint. I try to put two on each joint if possible and then my home run Lisfranc’s screw thrown in the way that – in the fashion that I identified two earlier.

And then this is another person, 34 years old, Lisfranc’s fracture in a motor vehicle accident and again, the same idea, same construct. This is the one I favor. In this case, I did not need to address the first metatarsal cuneiform because it was the cuneiform more so that extruded out, not the first metatarsal.

And then finally, very similar to that of the second example I showed you. 69-year-old, climbing upstairs in Maryland, fell down awkwardly and in the same construct. So Lisfranc’s injuries, take home points, they’re often misdiagnosed. That misdiagnosis several years later, leads to posttraumatic osteoarthritis and chronic pain in a diabetic to miss a Lisfranc’s injury is to almost guarantee that they’re going to have Charcot on uncontrolled diabetic. So really, really open your eyes to that mid foot injury.

[36:02]

Make sure that you’re treating it appropriately, make sure you’re ordering the right tests. ORIF is much more expensive because it’s more surgical procedures than primary arthrodesis and primary arthrodesis has satisfactory, comparable if not, improved results when compared to primary arthrodesis – I mean when compared to ORIF.

Thank you for your time.

Tape Ends [0:36:30]