Lisfranc fracture dislocation Mr MS Siddique MD FRCS MCh Orth FRCS Tr & Orth Miss E Robinson & Dr S Lyons Newcastle upon Tyne Hospitals NHS Trust

Importance of Diagnosis Incidence is 1 in 55,000 Account for 0.2% of all fractures Missed diagnosis leads to poor prognosis

Anatomy Mortise of Lisfranc Shallow mortise > Inj Peicha 2002 JBJS

Total Ankle Replacement

Mechanism of Injury Axial loading (toes dorsiflexed, ankle in equinus) Rotational forces (medial/lateral) with forced forefoot abduction

Presentation Ecchymosis Pain, swelling & tenderness Painful passive abduction/ pronation Midfoot instability Wt. Dorsalis pedis absent Compartment syndrome

Classification Hardcastle 1982 Myerson 1986 Type A All MT Complete Displacement Type B Partial Incongruity One or more MT Displacement 1 Medial 2 Lateral Type C Divergent Pattern 1 Partial Incongruity 2 Total Incongruity

Investigation X- Rays

Fleck sign

Investigation X- Rays Stress Views CT / MRI

Management Non Surgical Not fit for surgery Stress views FWB stable Diastasis <2mm cuneiforms & metatarsals <15˚ talometatarsal angle

Literature Recommendation No role of close reduction & POP without fixation Up to 60% failure rate Poor long term result Level IV Evidence Jeffreys 1963, Goossens 1983

Operative Options Close Reduction Percutaneous K Wiring Transarticular Fixation Arthrodesis

Perfect closed reduction Diastasis <2mm cuneiforms & metatarsals <15˚ talometatarsal angle

Our preference Reduce & fix the intra-articular fracture without crossing the articular surfaces Buttress the fracture dislocation of joint with mini-plate if unstable

Open reduction & Fixation

Dorsal plate Vs Transarticular screws Similar Ability to reduce & Resist displacement 1st & 2nd TMTJ Alberta et al Foot & Ankle int 2005

Not Recommended POP Immobilisation without reduction ORIF with K wires of 1st , 2nd & 3rd TMTJ ORIF with Transarticular screws TMTJ Primary Arthrodesis of 4th & 5th TMTJ

ORIF K Wiring Cadaveric Model

Open reduction & Fixation

Open reduction & Fixation

Open reduction & Fixation

Arthrodesis Unable to achieve quality reduction or stabilise without penetrating the articular surfaces. Rate arthritis 17% anatomic reduction 80% non-anatomic reduction

Primary arthrodesis for ligamentous injuries 41 patients 42 months follow up AOFAS ORIF Arthrodesis 68.6 88 Level 1 study Ly & Coetzee JBJS 2006

Arthrodesis for ligamentous injuries Poor healing potential of ligaments Loss of correction Greater deformity Degenerative arthritis Level 1 study Ly & Coetzee JBJS 2006

Complications Midfoot arthritis Compartment Syndrome Complex regional pain syndrome

Outcome Complete reduction : complete satisfaction NO Initial articular damage or inadequate reduction directly correlates with OA Arntz et al 1988

Outcome Precise anatomical reduction : optimal result Buzzard & Briggs 1998 Poor outcome in compensation claim cases Calder et al 2004

Summary Investigate fully if suspect Outcome : Precise reduction Plate fixation : Transarticular screws Arthrodesis : Unable to achieve quality reduction

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