Lisfranc ORIF / Arthrodesis Technique 28615

synonyms:

Lisfranc Arthrodesis / ORIF CPT

• 28606 (Percutaneous skeletal fixation of tarsometarsal joint dislocation, with manipulation)
• 28615 (Open treatment of tarsometatarsal joint dislocation, with or without internal or external fixation)
• 28730 (Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse

Lisfranc Arthrodesis / ORIF Indications

• Acute Displaced Lisfranc fx-dislocation with ligament instability (TMT joint displaced greater than 2mm)
• Chronic Lisfranc injuries (>6weeks)

Lisfranc Arthrodesis / ORIF Contraindications

• Soft tissue compromise
• Inadequate arterial inflow

Lisfranc Arthrodesis / ORIF Alternatives

• Non-op treatment

Lisfranc Arthrodesis / ORIF Pre-OP Planning

• K-wire fixation has been shown to often lead to migration of pins, pintract infection, loss of reduction and should not be used except int he 4th and 5th TMT joints.
• Avoid arthrodesis of the more mobile 4th and 5th tarsometatarsal joints even in the presence of radiographic arthrosis. (Sangeorzan, Foot Ankle 1990;10;193-200).
• Smoking is prohibited, especially for patients undergoing fusion.
• Use pre-op xrays of the normal side to plan surgery and bring the to the OR to assess reduction intraoperatively.
• For patients with chronic injuries/erosions bone graftsmay be needed.
• Primary arthrodesis is performed as described below, except cartilage and fibrous tissue are resected and the joints are decorticated before fixation. (Ly TV, JBJS 2006;88:514).
• Lisfranc Case Card.

Lisfranc Arthrodesis / ORIF Technique

• Sign operative site.
• Pre-operative antibiotics, +/- regional block.
• Supine position on radiolucent operating table. All bony prominences well padded. tourniquet high on thigh.
• General endotracheal anesthesia
• Examination under anesthesia.
• Prep and drape in standard sterile fashion.
• Dorsal incision between 1st and 2nd web space
• EHL, deep peroneal nerve, DP artery identified and retracted as a unit
• expose 1st, 2nd, TMT joints
• Debride hematoma, small, irreducible bone fragments
• Reduce beginning medially progressing laterally
• Align medial aspect of 1st MT with medial cuneiform to reduce 1st TMT.  Expose entire medial aspect of 1st TMT joint to ensure no plantar gapping exists
• Provisional fixation with k-wire, final fixation=3.5/2.7mm coutersunk fully threaded screw from gase of 1^stMT into medial cuneiform.
• 2^nd MT reduced to medial border of middle cuneiform, k-wire>3.5/2.7mm fully threaded countersunk screw from base of 2^ndMT into middle cuneiform.
• 3.5mm screw from medial cuneiform into base of 2^ndMT
• Dorsal incision between 3^rd 4^th MT, 3^rd TMT joint reduced >k-wire>3.5/2.7mm countersunk screw from base of 3^rdMT into lateral cuneiform
• 4^th, 5^thTMT joints usually occurs with reduction of first three and is fixed with percutaneous k-wire fixation
• If pt has associated nutcracker cuboid fracture, must anatomically reduce with distraction bone grafting and plating.  May need intra-op ex fix for distraction. (Sangeorzan JBJS BR 1990;72:376)
• Navicular fractures fixed with 3.5/2.7mm screws via extended dorsal incisions
• Irrigate
• Close in layers.
• SLC, non-weight bearing

Lisfranc Arthrodesis / ORIF Complications

• Compartment syndrome
• Cellulitis / wound infection
• Contracture (especially if skin grafts are needed to close open wounds)
• CRPS
• Vascular injury: dorsalis pedis artery often disrupted (mutiple branches of ant/post tibial A. therfore usually not a problem)
• Superficial peroneal nerve palsy
• Post traumatic arthritis (dependent on injury to articular cartilage and failure to achieve an anatomical reduction)
• Hardware failure / Broken screws
• DVT/PE
• Incomplete reduction or redislocation: frequenlty results in permanent disability with chronic pain,
• Postraumatic deformity (usually planovalgus)with difficulty wearing shoes.
• Chronic pain
• Malunion (second tarsometatarsal joint dorsolateral angulation most common).
• Nonunion

Lisfranc Arthrodesis / ORIF Follow-up care

• Post-op: Bulky-Jones Posterior splint, NWB, elevation
• 7-10 Days: Wound check, confirm reduction on xrays. Short-leg cast, NWB
• 6 Weeks: Remove 4th,5th MT pins at 6-8 weeks. Place in cam-walker / fracture boot. Begin partial weight bearing at 10 weeks.
• 3 Months: Review xrays. Wean out of cam-walker.
• 6 Months: Fit custom-molded semirigid orthotic with arch support. Progress with activities.
• 1Yr: Assess outcomes. Follow-up xrays. Symptomatic screws may be removed after 16wks
• Outcome measures: AOFAS midfoot score.

Lisfranc Arthrodesis / ORIF Outcomes

• (Myerson, Foot ankle 1986;6:225)
• CR casting = 20% good/excellent results
• CRPP = 53% good/excellent
• ORPP= 78% good/excellent
• ORIF=93% good/excellent in closed injuries worse for open injury (Arntz, JBJS AM 1988;70:173)
• Early restoration of joint congruity has improved outcomes over nonanatomic treatments. Brunet JA, Wiley JJ: The late results of tarsometatarsal joint injuries.  J Bone Joint Surg 1987;69B:437-440.
• (Arntz CT, JBJS 1988;70A:173).
• Outcome measures: AOFAS midfoot score.

Lisfranc Arthrodesis / ORIF Review References

• Sangeorzan BJ, in Masters Techniques in Orthopaedic Surgery: The Foot and Ankle, 2nd Ed, Lippincott, 2002
• Rockwood and Green's Fractures in Adults 6th ed, 2006
• Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006 Mar;88(3):514-20.
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