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ORIF of Lisfranc’s Fracture


- Indications for ORIF:
    - failure of closed reduction and pecutaneous pin fixation;
    - fractures presenting w/ more than than 2 mm of displacement and greater than 15 deg of talometatarsal angulation);
           - young competitive atheletes may require anatomic reduction;
    - disrupted skin and excessive swelling are relative contra-indications for ORIF;

- Technique:
    - exposure:
    - reduction:
          - open the capsule of the 2nd MT-middle cuneiform to expose the joint surfaces;
    - implants: 3.5 mm or 4.5 mm screws (either cortical or cannulated);
    - fixation statedgy:
          - medial-middle cuneiform articulation:
                 - if it is displaced, it is reduced and held w/ K wires;
          - 1st metatarsal - medial cunieform articulation:
                 - ensure that navicular-cuneiform complex is intact;
                 - ensure that the 1st metatarsal is plantar flexed to an appropriate degree (this is often difficult to judge);
                 - 1st TMT joint was aligned by opposing medial border of medial cuneiform to the medial border of 1st metatarsal;
                 - plantar-medial aspect of this joint needs to be visualized and assurance made that there is no plantar gap;
                 - notch is made in dorsal cortex of  proximal shaft of 1st metatarsal about 1.5 to 2 cm distal to the joint;
                        - it minimizes prominence of the screw head under the skin and prevents screw head from causing frx displacement;
                 - K wire is inserted from upper edge of notch across base of first cuneiform, aiming in a slight plantar direction;
                 - the cannulated screw is not placed until the other joint are reduced w/ K wires (to ensure that screws will not impinge on each other);
                 - in male pts w/ large 1st metatarsal shaft, use 4.0 to 4.5 mm cannulated screws (or alternatively use, 3.5 mm cortical lag screw);
                 - screw length is typically 35 to 40 mm;
          - 2nd metatarsal-medial cuneiform (lisfranc's complex);
                 - reduction of frx dislocation of 2nd metatarsal is essential, but fixation is optional especially if 2nd metatarsal is fractured;
                 - one option is stabilization of 2nd metatarsal base to middle cuneiform w/ a 4.0 cannulated screw;
                 - lisfranc screw::
                         - insertion of cannulated screw (4.0 mm) from medial cuneiform into base of second metatarsal;
                         - increases the stability of the fixation;

          - 3rd metatarsal:
                 - if base of 2nd metatarsal is frx'ed, procede to reduction of 3rd cuneiform joint;
                 - in some cases a second dorsal incision is required for this reduction between the 3rd and 4th metatarsals to expose the 3rd metatarsocuneiform joint;
          - 4th and 5th metatarsal - cuboid joints:
                 - in most cases, reduction of the medial three rays will tend to reduce the 4th and 5th metatarsals;
                 - these metatarsals have more mobility that medial ones and therefored, rigid fixation is more likely to results in symptomatic stiffness;
                          - hence these joints may be best fixed with K wires rather than screws;
                 - further, the second incision, risks wound slough;
                 - if possible consider use of percutenous pins for fixation, from bases of 4th and 5th metatarsal shafts into the cuboid;
                 - if percuneous pins are not considered adequate, then consider percutaneous screw insertion through the metatarsal shaft, into the cuboid;

- Complications:
    - broken hardware: screws may break in up to 25% of patients;
    - degenerative arthritis: may be seen in upto 25% of patients

Outcome After Open Reduction and Internal Fixation of Lisfranc Joint Injuries

Intramedullary transmetatarsal Kirschner wire fixation of Lisfranc fracture-dislocations.

- Case Examples:

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