Open Reduction and Internal Fixation
A calf tourniquet is applied and inflated to 250 mm Hg. The surgical
approach is exactly the same for open reduction and internal fixation and for
primary fusion. Depending on the instability pattern, one or two dorsal,
longitudinal incisions are made. The first incision is made between the first
and second metatarsals, and it might be the only incision needed when the
instability pattern is divergent with instability between the first and second
metatarsals as well as between the medial and middle cuneiforms
(Fig. 1).
A 6-cm incision is made just lateral to the extensor hallucis longus
tendon. The distal end of the incision is about 3 cm distal to the level of
the first tarsometatarsal joint. Care should be taken to protect the sensory
branches of the superficial peroneal nerve, which are almost invariably
encountered during the approach. It is usually easier to retract the
superficial nerve laterally along with the dorsalis pedis artery. At the
distal end of the incision, a vein is typically found crossing the field; it
should be cauterized if it is in the way
(Fig. 2).
As a result of the ligamentous disruption, the unstable segments are
usually easily recognized. Most often, the dorsal capsular structures are also
disrupted. The hematoma is evacuated from the joints to allow adequate
exposure and visualization. Typically, even in feet with predominantly
ligamentous injuries, a small avulsion fracture is seen at the medial base of
the second metatarsal where the Lisfranc ligament attaches.
CRITICAL CONCEPTSINDICATIONS:Our selective indications for a primary fusion of the Lisfranc joint
are:Major ligamentous disruptions and multidirectional instability of the
Lisfranc jointsA comminuted intra-articular fracture at the base of the first or second
metatarsalCrush injuries of the midfoot with an intra-articular
fracture-dislocationCONTRAINDICATIONS:Lisfranc injuries in children with open physesSubtle Lisfranc injuries with minimal or no displacementUnidirectional Lisfranc instabilityUnstable extra-articular fractures of the metatarsal bases with unknown
amounts of ligamentous disruptionPITFALLS:There are superficial sensory nerves in both of the incision areas.
Formation of a neuroma could cause considerable morbidity as it is often
difficult to find comfortable shoes when there is a neuroma on the dorsum of
the foot.The dorsalis pedis artery and the deep peroneal nerve are usually
encountered in the interval between the extensor hallucis longus and brevis
and should be identified and carefully protected.The dorsalis pedis artery courses from dorsal to plantar in the foot
between the first and second metatarsals about 1 cm distal to the first
tarsometatarsal joint. With drilling and placement of the so-called home-run
screw from the medial cuneiform to the base of the second metatarsal, this
artery is at risk and could be damaged.The third tarsometatarsal joint is much farther lateral than is often
appreciated. There should therefore be at least a 4-cm bridge between the two
incisions, and it is preferable to confirm one's location under fluoroscopy
before the second incision is made. If the second incision is too medial, it
may be very difficult to access the third and fourth tarsometatarsal
joints.Due to the angle required to insert screws, it is sometimes very difficult
to achieve a good compression when placing a screw across the third
tarsometatarsal joint. An alternative is to use a staple, which is usually
easier to position and insert.The first tarsometatarsal joint is about 30 mm deep. Without adequate
exposure and distraction, it might not be possible to remove all of the
cartilage from the plantar third of the joint, which would place the
metatarsal in a dorsiflexed position when it is compressed for
arthrodesis.AUTHOR UPDATE:Even though the data support the use of a primary fusion for mainly
ligamentous disruptions, one should not use this technique too liberally for
all Lisfranc injuries. An example of an injury for which the technique is
inappropriate is the hyper-plantar flexion injury through the Lisfranc joint
seen in football players. With this mechanism, there is often a partial or
complete disruption of the dorsal structures, but the strong plantar ligaments
are typically intact. If there is not multidirectional instability with
manipulation, a fusion should not be done. Patients with this less severe
injury will do reasonably well with conventional open reduction and internal
fixation.Since our original paper was published, no substantial changes have been
made in the surgical technique.
CRITICAL CONCEPTS
INDICATIONS:
Our selective indications for a primary fusion of the Lisfranc joint
are:
Major ligamentous disruptions and multidirectional instability of the
Lisfranc jointsA comminuted intra-articular fracture at the base of the first or second
metatarsalCrush injuries of the midfoot with an intra-articular
fracture-dislocation
Major ligamentous disruptions and multidirectional instability of the
Lisfranc joints
A comminuted intra-articular fracture at the base of the first or second
metatarsal
Crush injuries of the midfoot with an intra-articular
fracture-dislocation
CONTRAINDICATIONS:
Lisfranc injuries in children with open physesSubtle Lisfranc injuries with minimal or no displacementUnidirectional Lisfranc instabilityUnstable extra-articular fractures of the metatarsal bases with unknown
amounts of ligamentous disruption
Lisfranc injuries in children with open physes
Subtle Lisfranc injuries with minimal or no displacement
Unidirectional Lisfranc instability
Unstable extra-articular fractures of the metatarsal bases with unknown
amounts of ligamentous disruption
PITFALLS:
There are superficial sensory nerves in both of the incision areas.
Formation of a neuroma could cause considerable morbidity as it is often
difficult to find comfortable shoes when there is a neuroma on the dorsum of
the foot.The dorsalis pedis artery and the deep peroneal nerve are usually
encountered in the interval between the extensor hallucis longus and brevis
and should be identified and carefully protected.The dorsalis pedis artery courses from dorsal to plantar in the foot
between the first and second metatarsals about 1 cm distal to the first
tarsometatarsal joint. With drilling and placement of the so-called home-run
screw from the medial cuneiform to the base of the second metatarsal, this
artery is at risk and could be damaged.The third tarsometatarsal joint is much farther lateral than is often
appreciated. There should therefore be at least a 4-cm bridge between the two
incisions, and it is preferable to confirm one's location under fluoroscopy
before the second incision is made. If the second incision is too medial, it
may be very difficult to access the third and fourth tarsometatarsal
joints.Due to the angle required to insert screws, it is sometimes very difficult
to achieve a good compression when placing a screw across the third
tarsometatarsal joint. An alternative is to use a staple, which is usually
easier to position and insert.The first tarsometatarsal joint is about 30 mm deep. Without adequate
exposure and distraction, it might not be possible to remove all of the
cartilage from the plantar third of the joint, which would place the
metatarsal in a dorsiflexed position when it is compressed for
arthrodesis.
There are superficial sensory nerves in both of the incision areas.
Formation of a neuroma could cause considerable morbidity as it is often
difficult to find comfortable shoes when there is a neuroma on the dorsum of
the foot.
The dorsalis pedis artery and the deep peroneal nerve are usually
encountered in the interval between the extensor hallucis longus and brevis
and should be identified and carefully protected.
The dorsalis pedis artery courses from dorsal to plantar in the foot
between the first and second metatarsals about 1 cm distal to the first
tarsometatarsal joint. With drilling and placement of the so-called home-run
screw from the medial cuneiform to the base of the second metatarsal, this
artery is at risk and could be damaged.
The third tarsometatarsal joint is much farther lateral than is often
appreciated. There should therefore be at least a 4-cm bridge between the two
incisions, and it is preferable to confirm one's location under fluoroscopy
before the second incision is made. If the second incision is too medial, it
may be very difficult to access the third and fourth tarsometatarsal
joints.
Due to the angle required to insert screws, it is sometimes very difficult
to achieve a good compression when placing a screw across the third
tarsometatarsal joint. An alternative is to use a staple, which is usually
easier to position and insert.
The first tarsometatarsal joint is about 30 mm deep. Without adequate
exposure and distraction, it might not be possible to remove all of the
cartilage from the plantar third of the joint, which would place the
metatarsal in a dorsiflexed position when it is compressed for
arthrodesis.
AUTHOR UPDATE:
Even though the data support the use of a primary fusion for mainly
ligamentous disruptions, one should not use this technique too liberally for
all Lisfranc injuries. An example of an injury for which the technique is
inappropriate is the hyper-plantar flexion injury through the Lisfranc joint
seen in football players. With this mechanism, there is often a partial or
complete disruption of the dorsal structures, but the strong plantar ligaments
are typically intact. If there is not multidirectional instability with
manipulation, a fusion should not be done. Patients with this less severe
injury will do reasonably well with conventional open reduction and internal
fixation.
Since our original paper was published, no substantial changes have been
made in the surgical technique.
It is important at this point to determine which joints are involved in the
instability pattern. This is accomplished visually and under fluoroscopy. The
hindfoot is stabilized while the forefoot is manipulated, first with an
abduction-adduction force and then with plantar flexion and dorsiflexion
stresses.
For open reduction and internal fixation, care is taken to débride
the joints adequately. Any small, free pieces of cartilage should be removed.
At this point, a reduction is attempted. A large-toothed reduction clamp is
used to maintain the reduction between the second metatarsal and the medial
cuneiform. If there is any concern about the accuracy of the reduction, it is
advisable to make a second, more lateral incision to facilitate exposure and
visualization of the joint.
If the first tarsometatarsal joint is unstable, it is secured first. The
reduction and alignment are confirmed visually and under fluoroscopy. A
temporary Kirschner wire is inserted to stabilize the joint. This is followed
by insertion of a plain 3.5 or 4-mm cortical screw, depending on the size of
the patient, to internally fix the joint. We typically insert the screw from
the medial cuneiform into the first metatarsal, but it can also be inserted
from the first metatarsal into the medial cuneiform.
This creates a stable medial column as a foundation on which the remaining
injured metatarsals can be secured. The next step is to reduce the second
metatarsal base into its keystone position. A clamp is used to pull the
metatarsal base adjacent to the lateral aspect of the first metatarsal and the
medial cuneiform.
The most common mistake made here is to inadvertently elevate the second
metatarsal in the process of screw placement. It is therefore always
worthwhile to visually, but also radiographically, check the alignment of the
metatarsals. If it is possible to obtain very good compression with a clamp,
these screws are inserted in a non-compression fashion. However, if there is
any concern about a residual gap, not caused by retained debris, the screw may
be inserted in a lag compression mode to close the gap
(Fig. 3).
If there is instability between the cuneiforms, the same incision is used
and the screw from the medial aspect of the medial cuneiform and the base of
the second metatarsal is augmented with an inter-cuneiform screw
(Figs. 4-A and 4-B).
Primary Fusion
The exact same approach and principles are used in performing a primary
fusion; the only added step is that the articular cartilage is removed from
the opposing surfaces of the joints. This is done with small rongeurs, curets,
and small osteotomes. The goal is only to remove the cartilage and expose
subchondral bone. It is not necessary or advisable to use a saw to prepare the
surfaces, as saw cuts might shorten the metatarsals and cuneiforms, which is
not of any benefit.
The first tarsometatarsal joint is about 30 mm deep. In the absence of
full, broad exposure of the depth of the joint, there is a tendency to fuse it
in dorsiflexion2. A
small lamina spreader is very helpful to allow full visualization of the
entire joint (Fig. 5).
After complete removal of the cartilage, the surfaces are prepared for
fusion by feathering them with a small osteotome. The screw configuration is
usually exactly the same as described above, but the screws are always applied
in a compression fashion.
After stabilization of the medial two rays, the stability of the third,
fourth, and fifth rays should be checked. It is not uncommon for the third ray
to be unstable. If so, it should be reduced and fixed or fused as well. If the
fourth and fifth rays are unstable, they are reduced under fluoroscopy and
stabilized with 0.62-mm-diameter Kirschner wires.
We believe in the liberal use of a two-incision approach, as adequate
exposure of the lateral corner of the second metatarsal base and the lateral
cuneiform can be very difficult to obtain through a single dorsomedial
incision.
The second incision is centered over the fourth metatarsal. The most common
mistake is to make the incision too far medial; proper placement of the
incision may be aided by fluoroscopic guidance and identification of the
intended osseous targets. The foot should be internally rotated to achieve a
true view of the fourth metatarsal. If the image is made with the foot in a
neutral position, there is too much overlap between the lateral three
metatarsals to accurately determine the position of the fourth ray.
This lateral incision endangers the lateral branches of the superficial
peroneal nerve, which should also be protected. The incision is usually just
lateral to the extensor digitorum longus tendon, which is easily elevated to
expose the underlying extensor digitorum brevis. The brevis muscle belly is
divided longitudinally with sharp dissection to allow visualization of the
third and fourth tarsometatarsal joints and the lateral half of the second
tarsometatarsal joint.