• Young adult with polytrauma

• Ipsilateral fracture dislocation hip

• Ipsilateral comminuted fracture upper end tibia

• Open Fracture contralateral tibia

• WITH….

In most advanced trauma centre…

Missed lisfranc: now what?

Dr Rajiv Shah‘Foot & Ankle orthopaedics’

Foot & Ankle SurgeonPresident, Indian Foot & Ankle Society

Missed Lisfranc

• Lisfranc injury is missed more often that not!

• Reconstruction beyond three weeks usually not done

• Missed lisfranc lands up in to post traumatic midfoot arthrosis

• Should be treated with midfoot fusion

Midfoot arthritis:

Chronic foot pain

Functional disability

Guidelines lacking

To rigid on push off

Midfoot Arthritis: Diagnosis

• Pain• Tenderness• Deformity

– Loss of Arch– Midfoot Abduction

• Gait Abnormality– Non Rigid Arch During

Push-Off

Physical Exam

• N/V status

• Skin condition

• Palpate joints

• Assess alignment– Pes planus– Abduction

Physical Exam

• Painful motion?

Radiology

• X-Rays– AP,Lateral, & 30o Oblique

• Parallel to TMT Joint Surfaces– 15-20o Cephalad

– Weight-Bearing

• CT Scan

Radiology Findings

• X-rays:

• Joint space narrowing

• Osteophytes

• Subchondral sclerosis & cysts

• CT scan:

• Axial and 30° Semi--‐Coronal Cuts

• Articular Incongruity

• Bone Exostoses

• MRI:

• Osteochondral Lesions

• Osteomyelitis

• Extent of Talar Avascular Necrosis

Diagnostic or Therapeutic Injections

•25-33% accuracy with palpation alone•Must use Fluoro or US

•Extravasation of dye in approx. 20%

Aims of treatment:

Pain relief by enhancing stability

Fusion in functional position

Plantigrade foot

Non-Op Treatment

• NSAID

• Activity Modification

• Local steroids

• Stiff soled shoes

• Rocker soled shoes

• Full length steel shank

• Orthotics: UCBL, hinged AFO

• Carbon footplates

Non-op treatment

• Carbon footplate

Carbon Footplate 70% pain reduction

                                               

Steel shank shoe

Conservative mx:

Carbon foot plate

3Q insert

Operative Principles

• Fuse only what is painful– Most likely the medial

column• 1st TMT, Navicular-

medial cuneiform

• 2nd TMT and N-MC joints

• +/- 3rd joints

– Don’t fuse 4, 5 TMT• Peroneus tertius

• Resect if necessary but this is rare

• Don’t forget Gastroc

Operative Principles

• Lazy “C” incision– If going laterally then second incision– FULL thickness flaps

• Denude Cartilage– Untoothed Laminar Spreader– Drill with K-wire to promote healing

• Build the fusion from the medial side to the lateral aspect

• Hintermann retractor

Operative Principles

• K-wire for temporary fixation– Use crossed screws, dorsal plates

compression staples dorsal locking plate

• Stability of the fusion can be improved by plates

Tarso MT Joint

Midfoot Joints

Plating allows for reliable fusionCan Hold corrected deformity

Midfoot plusTM Joints

Dorsiflexion of toes while tightening screws reduces GAP in the joints

Operative Principles

• Mini Fluoroscopy decreases radiation exposure

• Full thickness closure with nylon sutures– Leave in for 3 weeks; elevate foot

• Well padded splint/cast for 8 weeks NWB

• Walking cast for 4 more weeks

• Xrays at 8 and 12 weeks

• Additional f/u 18 weeks

Case Example

• Female aged 33 years

• Pain, swelling & inability to ambulate

• 4.5 months post trauma

Original X-ray

At surgery….

Case example:

Case example:

Case example:

1st-3rd TMT fusion Isolated 2nd fusion

Pearls• Don’t do this until the

patient begs you for it…– Outcomes 50-80%

good…not great

• Complications: Non-union, wound problems, infection, nerve injury, continued pain, prominent hardware

That’s all…

Thank you all..