Advice needed for unhealed Lisfranc injury

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Hi
some advice needed from those with more knowledge than myself. Have a patient with nasty Lisfranc injury fracture/dislocations three years ago motorbike rider lateral impact 20/miles hour. ORIF initally OK failed. Orthotics failed. Now surgical shoes with orthotists insole. Rigid deformity and pain presenting symtoms. Advice re further surgical intervention and podiatry.



Thanks

 

Zaffie

Unfortunately you havent given a lot of information to go on...and the x-rays are too poor quality and non-WB to assess effectively.

Essentially Lisfranc joint injuries invariably go sour. The question is often how much of the joint to fuse (ie 1-2, 1-3, 4-5, 1-5).

The x-rays do show one of the screws tracking well into the intercuneiform (latera/central) joint, and possibly pushing the lateral over. I cant tell how well the fusions have worked, and what the sagittal position is like.

I would do the following:

1. palpate which individual joints are still tender
2. get fresh digital x-rays in weight bearing angle and base of gait
3. possibly further imaging if these are unhelpful
4. consider diagnostic block of selected tarso-MT joints with a long-acting local to determine suitability for additional fusions

If you can provide further information about nature, location, aggrevating factors etc it would help, but this is really essentially post-traumatic arthritis - and can only be managed either with orthoses (which seem to have failed) or additional revision surgery (ie fusions).

Hope this helps,

LL (i DO like Lisfranc injuries - hence my moniker)

 

Lucky Lisfranc
I thought you might have an interest hence your moniker.
Thanks for advice had not thought about diagnostic block. I know x rays are poor have seen more recent ones do not have them they show a hole in navicular and extensive arthritis. Every thing seems to have failed in this foot. Revision surgery was discussed but there is a distinct possibility of this failing and resulting in amputation. Dorsalis pedis pulse was absent after injury and is not palpable to this day. Patient had fracture dislocation of medial cuneiform fracture of third met and navicular. One surgeon says is not Lisfranc two say it is!. I am no expert but thought it met criteria for Lisfranc. Have read around subject including articles posted by admin but have not come across much that would seem to apply to this case. Am I right in thinking Lisfranc can be caused by low velocity/impact?
Thanks

 

Zaffie

Lisfranc's joint injuries can occur though seemingly inoccuous events. I have had patients that step into an unforeseen 'pothole' and 'twist' their foot - and besides the initial presentation of a 'sprain' at the emergency department, go on to develop post-traumatic OA several years later.

Anything that disrupts that dorsal or plantar ligamentous tarso-metatarsal structures can lead to subtle diastasis which is easily overlooked. Sometime a reverse AP (ie PA) view can pick these up.

Your gentleman obviously has sustained more severe injuries to other locations besides Lisfranc's joint, and his prognosis is probably poor. Despite damage to dorsalis pedis, I would not discount further surgery - its just that it will be difficult and any surgeon will shudder at the though of such a complex undertaking, and be tempted to just walk away. The perforating peroneal artery will often take up the slack (easily checked with handheld Doppler), and posterior tibial is really by far the most important vessel anyway. The DP is small by comparison.

You can easily prove sufficient vascularity to the area through checking for distal flow via arteriogram, or TcPO2 studies. Then it will be up to you to convince your local surgical colleagues to take him on, I suspect. This could mean multiple midfoot fusions to gain stability and take away pain. Amputation is the 'easy' way out, and may well be required, but will lead to obvious disability long term,

Or let nature take its course...

Let us know how it pans out,

LL

 

Lucky Lisfranc
thanks for your advice. I have never seen an injury of this nature. Poor bloke is obviously going to have trouble rest of his life. Orthopedics are running scared can't say I blame them. Symptomatic relief is all I hope to achieve am going back to old fashioned cushioning insoles to see if this will help.
Thanks

 

Zaffie:

I see a fair number Lisfranc's joint fracture-dislocation injuries in my practice. These are commonly missed initially so one must have a high index of suspicion for these injuries since the radiographic changes that occur are often sometimes very subtle.

Looking at the radiographs you provided does not give us a lot of information other than 1) they are of poor quality and 2) the patient had a very serious injury to his foot. Now, three years since the injury, the patient's pain is probably due to progressive degenerative joint disease (DJD) in the 1st and 2nd metatarso-cuneiform joints and other surrounding joints. Here is my treatment plan for the patient:

1. Don't assume that just because "orthoses failed" that a better orthosis would not help more! Make the patient an orthosis with a 4 mm medial heel skive, 20 mm heel cup, 3-5 mm heel lifts, inverted 5 degrees, of 5 mm polypropylene or thicker and minimal arch fill with a 2-5 valgus forefoot extension under the 2nd to 5th metatarsal heads to reduce the dorsiflexion bending moments on the joints of the medial midfoot. These medial midfoot bending moments are the most likely biomechanical forces that are causing his pain with weightbearing activities. The idea here is to "invert the rearfoot and evert the forefoot" with the orthosis to "unload the medial column".

2. Put him into a cam-walker brace or immobilization cast for 4-6 weeks while orthoses are being made for him to reduce the inflammation in the joints before orthoses are dispensed.

3. Have him wear shoes/boots with as high of a heel height differential (i.e. 1" heel or greater) as possible to reduce the bending moments on the medial midfoot joints.

4. Have him ice the symptomatic areas of his foot 20 minutes twice a day and take NSAIDS regularly.

5. Relace the shoes (i.e. skip shoe lace holes around area of pain) to decrease the shoe-upper compression forces on the dorsal foot during weightbearing activities.

Surgery is always an option but even a very qualified podiatric or orthopedic surgeon will likely have a difficult time making his foot painfree. Generally, in cases like these that I have treated over the past two decades, the above treatment plan has allowed the individuals with similar injuries to be able to be comfortable enough to avoid further surgery as long as they can accept the fact that running and jumping sports will not be possible again.

Hope this helps. Merry Christmas!:santa:

 

I agree with LL and Kevin's comments about not much inforation. However, there is too much info in one area. You can read his name and DOB off of the X-rays. Here in the states, publishing private health info is a big no-no.

What activities hurt more / less. Where is it tender to palpate. Are there any unusual shoe wear patterns?

Regards, :santa:

Eric

 

Kevin
Thanks for advice i will follow it.
This was not a subtle injury. Apparently according to patient medial border was shunted medially after impact. It was obvious that a gross dislocation had taken place. Dislocations were reduced in A and E as circulation had been compromised. Next day ORIF 4 months later screws removed. Deterioration ever since. Post traumatic arthritis with a vengeance

Thanks to every one for advice

 

Certainly this unfortunate fellow did not have a subtle injury. However, in many cases, Lisfranc fracture-dislocations are missed for months, if not years, before a proper diagnosis is made.

Zaffie, it would be very instructional for everyone following along if you could report back on this patient's progress once you have completed his treatment plan. In this way, your experiences will help teach many other podiatrists and other foot-health practitioners around this small world of ours.:drinks

 

Kevin
will report back with progress
Thanks for help every one