Case for small group discussion Lisfranc instability Case for small group discussion AOTrauma—Foot & Ankle Module 13: Midfoot Andrew Sands, US

Case description 55-year-old man Works for railroad as track worker Must carry heavy things and step over third rail Sustained twisting injury to foot 5’9” (1.80 m) and 165 lbs (75 kg): not an oversized person

Case description Seen in local emergency room Subsequently seen in office with residual midfoot pain Stress images taken

X-rays

Diagnosis Treatment options Nonoperative Internal fixation External fixation Fusion

Operation This was done (below) Comments?

2 months postoperative Continued pain after frame was removed

Longer term follow-up Presents 9 months later Why does the patient have continued pain? What would you do now?

Definitive operative plan Instability after pure ligamentous injury with continuous pain What is your plan? Evaluate if equinus present? Discuss management, calf release

Definitive surgery Tarsometatarsal (TMT) fusion to address instability Calf release if equinus present

Take-home messages If fracture or avulsion is present, it will heal bone to bone ORIF in perfect position will usually lead to healing but anatomic positioning is mandatory In case of a pure ligamentous injury, consider immediate fusion If fusing, you can use plates or screws and bone graft Evaluate for equinus and address if present Ly, Thuan V, and Coetzee, J Chris. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg Am. 2006; 88(3):514-520.