Open Reduction and Internal Fixation of Lisfranc/Tarsometatarsal Injuries

Indications

• Lisfranc/tarsometatarsal (TMT) injuries with instability and displacement

Treatment Options

• There is often an associated equinus contracture with this injury pattern, requiring a calf lengthening at the time of open reduction and internal fixation (ORIF). It is thought that performing a calf lengthening at this time helps prevent degeneration in the midfoot.

• Newer ideas on treatment include immediate fusion in the case of pure ligamentous injuries. The technique, approach, choice of implant and screw pattern, and technique are the same. The joint surfaces are prepared for fusion instead of pure ORIF.

• In the case of a nondisplaced injury, closed cast or controlled ankle movement (CAM) walker treatment (strict non–weight bearing) can be tried as long as the patient is warned that future fusion may be more likely.

Examination/Imaging

• On examination, the patient will report severe pain, worse than for a typical twisting injury. There will be midfoot swelling and ecchymosis (often with a plantar medial pattern).

• Plain radiographs are usually obtained.

  • Anteroposterior, oblique, and lateral views with weight bearing are obtained as tolerated.

    • On the anteroposterior view, the first TMT (1TMT) and second TMT (2TMT) joints are assessed for alignment and displacement. There is often a gap between the bases of the first metatarsal (1MT) and 2MT ( Fig. 22.1 ).

      

    • The third TMT (3TMT) can be best viewed on the oblique view. It should line up with the lateral cuneiform ( Fig. 22.2 ). The fourth MT (4MT) and fifth MT (5MT) bases are also viewed. The 4MT should line up with the cuboid border in this view.

      

    • On the lateral view, dorsal displacement at the TMT can be seen, indicating a higher energy pattern ( Fig. 22.3 ).

      

  • Intertarsal injuries and displacement should also be looked for. If they exist, they should be addressed first.

  • Stress view is taken.

    • Obtaining this view is painful and should be done under an ankle block in the operating room before ORIF.

    • The heel can be grasped with the contralateral hand and the forefoot with the ipsilateral hand. A gentle valgus stress can be applied ( Fig. 22.4 ).

      

    • In a typical homolateral pattern, the midfoot will displace (under radiograph views for documentation).

  • Computed tomography may be useful.

    • Can be helpful in assessing other associated tarsal injuries

    • Also provides good bony resolution

  • Magnetic resonance imaging (MRI) is useful in nondisplaced, purely ligamentous injuries ( Fig. 22.5 ).

    

Surgical Anatomy

• The main stabilizer of the midfoot is the plantar ligament, which goes from the plantar base of the medial cuneiform to the plantar medial base of the 2MT. The amount of force required to disrupt this ligament is considerable. However, the dorsal ligaments are not as strong and can be disrupted more easily. If ORIF is performed, it is often possible to repair these dorsal ligaments at the time of closure for added stability.

• Because there is essentially no soft tissue on the dorsum of the foot, care must be taken with the approach. Double dorsal incisions allow access to every area needed. Healing is without problem unless the area between the incisions is violated. The dorsal flap between the incisions is protected by the dorsalis pedis artery.

Portals/Exposures