1. 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

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

3. Anatomy
Mortise of Lisfranc
Shallow mortise > Inj
Peicha 2002 JBJS

4. Total Ankle Replacement

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

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

7. 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

8. Investigation
X- Rays

9. Fleck sign

10. Investigation
X- Rays
Stress Views
CT / MRI

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

12. 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

13. Operative Options Close Reduction Percutaneous K Wiring
Transarticular Fixation
Arthrodesis

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

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

16. Open reduction & Fixation

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

18. 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

19. ORIF K Wiring
Cadaveric
Model

20. Open reduction & Fixation

21. Open reduction & Fixation

22. Open reduction & Fixation

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

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

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

26. Complications Midfoot arthritis Compartment Syndrome
Complex regional pain syndrome

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

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

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

30. Thank you

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36. Thank you