122

COPYRIGHT © 2007 BY THE IOURNAI OÍ- BONE AND IOINT SURGILRY. INCORPORATED

Treatment of Primarily
Ligamentous Lisfranc Joint
Injuries: Primary Arthrodesis
Compared with Open Reduction
and Internal Fixation
Surgical Technique
By J. Chris Coetzee, MD, FRCSC, and Thuan V. Ly, MD
¡nvcitigation performed at the Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, Minnesota

The original scientific article in which the surgical technique was presented was published in JBfS Vol. 88-A, pp. 5M-52Ü, March 2006

ABSTRACT
BACKGROUND:
Open reduction and internal fixa-
tion is currently the accepted
treatment for displaced Lisfranc
joint injuries. However, even with
anatomic reduction and stable in-
terna! fixation, treatment of these
injuries does not have uniformly
excellent outcomes. The objective
of this study was to compare pri-
mary arthrodesis with open reduc-
tion and internal fixation for the
treatment of primarily ligamen-
tous Lisfranc joint injuries.
METHODS:
Forty-one patients with an iso-
lated acute or subacute primarily
ligamentous Lisfranc joint injury
were enrolled in a prospective,
randomized clinical trial compar-
ing primary arthrodesis with tra-
ditional open reduction and
internal fixation. The patients
continued
INTRODUCTION
There are subsets of Lisfranc injuries for which conventional open
reduction and internal fixation will have predictably poor results'.
The Lisfranc joints have very little inherent stability, and the result
of the injury depends somewhat on thequality of the scar tissue that
is formed. The clinical result in feet that have a primarily soft-tissue
injury with a Lisfranc joint dislocation may be worse than that after a
severe fracture-dislocation. For this reason, we prefer to perform an
arthrodesis of the medial two or three rays when we treat primarily
ligamentous injuries of the Lisfranc joint.
SURGICAL TECHNIQUE
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 inci-
DISCLOSURE: The authors did not receive any outside funding or grants in support of their research for or
preparation of this work. Neither they nor a member of their immediate families received payments or other
benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial
entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division,
center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member
of their immediate families, are affiliated or associated.

TlIF, lOURNA!. OF BONE & [OINT SURGERY • SURGICAL TfXHNIQUES
The surgical approaches are shown on a right foot. The medial incision is between the
first and second metatarsals. just lateral to the extensor hallucis longus tendon, The lat-
eral incision is at least 4 cm farther lateral, overlying the fourth metatarsal.
sion needed when the instahility
pattern is divergent with instahil-
ity between the first and second
metatarsals as well as hetween
the medial and middle cunei-
forms (Fig. 1).
A 6-cm incision is made just
lateral to the extensor hallucis
longus tendon. The distal end of
the incision is ahout 3 cm distal
to the level of the first tarsometa-
tarsal joint. Care should be taken
to protect the sensory branches
ol the superficial peroneal nerve,
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MARCH 2 0 0 7 • VOLUME 89-A • SUPPLEMENT 2, PART I - JBIS.ORG
ABSTRACT
which are almost invariably en-
countered 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 ligamen-
tous disruption, the unstable
segments are usually easily re-
cognized. Most often, the dorsal
capsular structures are also dis-
| continued
were followed for an average of
42.5 months. Evaluation was
performed with clinical examina-
tion, radiography, the American
Orthopaedic Foot and Ankle So-
ciety (AOFAS) Midfoot Scale, a
visual analog pain scale, and a
clinical questionnaire.
RESULTS:
Twenty patients were treated with
open reduction and screw fixa-
tion, and twenty-one patients
were treated with primary arthro-
desis of the medial two or three
rays. Anatomic initial reduction
was obtained in eighteen of the
twenty patients in the open-
reductio group and twenty of
the twenty-one in the arthrode-
sis group. At two years postop-
eratively, the mean AOFAS
Midfoot score was 68.6 points in
the open-reduction group and 88
points in the arthrodesis group
(p < 0.005). Five patients in the
open-reduction group had persis-
tent pain with the development of
deformity or osteoarthrosis, and
they were eventually treated with
arthrodesis. The patients who
had been treated with a primary
arthrodesis estimated that their
postoperative level of activities
was 92% of their preinjury level.
whereas the open-reduction group
estimated that their postopera-
tive level was only 65% of their
preoperative level (p < 0.005).
CONCLUSIONS:
A primary stable arthrodesis of
the medial two or three rays ap-
pears to have a better short and
medium-term outcome than open
reduction and internal fixation of
ligamentous Lisfranc joint injuries.
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CRITICAL CONCEPTS

INDICATIONS:
Our selective indications for a
primary fusion of the Lisfranc
joint are:
- Major ligamentous disruptions Extensor Hallucis Longus tendon
and multidirectional instabil-
ity 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 physes
• Subtle Lisfranc injuries with
minimal or no displacement A close-up view of a left foot demonstrates the extensor hallucis longus tendon tying me-
• Unidirectional Lisfranc instability dially. The dorsalis pedis artery and the deep peroneal nerve are lateral to the tendon
and will be encountered during the exposure. A branch of the superficial peroneal nerve
• Unstable extra-articular frac-
usually runs from lateral to mediai across the distal portion of the exposure. These
tures of the metatarsal bases
structures should be identified and protected.
with unknown amounts of liga-
mentous disruption

PITFALLS: predominantly ligamentous in- A large-toothed reduction clamp

• There are superficial sensory
nerves in both of the incision
areas. Formation of a neuroma
could cause considerable mor-
bidity as it is often difficult to
find comfortable shoes when
there is a neuroma on the dor-
sum of the foot.
• The dorsatis pedis artery and
the deep peroneal nerve are
usually encountered in the in-
terval between the extensor
hallucis longus and brevis and
should be identified and care-
fully protected.
continued
rupted. The hematoma is eva-
cuated from the joints to allow
adequate exposure and visualiza-
tion. Typically, even in feet with
juries, a small avulsion fracture
is seen at the medial base of the
second metatarsal where the Lis-
franc ligament attaches.
It is important at this point
to determine which joints are
involved in the instability pat-
tern. This is accomplished visu-
ally and under fluoroscopy. The
hindfoot is stabilized while the
forefoot is manipulated, first
with an abduction-adduction
force and then with plantar flex-
ion and dorsiflexion stresses.
For open reduction and in-
ternal fixation, care is taken to
débride the joints adequately.
Any small, free pieces of carti-
lage should be removed. At this
point, a reduction is attempted.
is used to maintain the reduction
between the second metatarsal
and the medial cuneiform. If
there is any concern about the ac-
curacy of the reduction, it is ad-
visable to make a second, more
lateral incision to facilitate expo-
sure and visualization of the joint.
If the first tarsometatarsal
joint is unstable, it is secured
first. The reduction and align-
ment are confirmed visually and
under fluoroscopy. A temporary
Kirschner wire is inserted to sta-
bilize 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 inter-
nally fix the joint. We typically
insert the screw from the medial

T H E JOURNAL OF BONE & | O I N T SURGERY • SURGICAL TECHNIQUES
The typical screw placement for a dislocation of the first, second, and third Lisfranc
joints in a ieft foot. The first ray is immobilized first, tollowed by the second and then the
third rays.
cuneiform into the first meta-
tarsal, but it can also be inserted
from the first metatarsal into the
medial cuneiform.
This creates a stable me-
dial column as a foundation
on which the remaining injured
metatarsals can be secured. The
next step is to reduce the sec-
ond metatarsal base into its key-
stone position. A clamp is used
to pull the metatarsal base adja-
cent 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 radiographi-
cally, check the alignment of the
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MARCH 2007 • VOLUME 8 9 - A • SUPPLEMENT 2, PART l • IBIS.ORG
metatarsals. If it is possible to ob-
tain 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 be-
tween 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 aug-
mented 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
CRITICAL CONCEPTS
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 metatar-
sal. 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 prefer-
able to confirm one's location
under fluoroscopy before the
second incision is made. If
the second incision is too me-
dial, 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 tar-
sometatarsal joint. An alterna-
tive 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 distrac-
tion, 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 po-
sition when it is compressed for
arthrodesis.
Step is that the articular carti-
lage is removed from the oppos-
ing surfaces of the joints. This is
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In this injury pattern, the force went through the first intermetatarsal joint (with a complete disruption of the Lisfranc iigament). then went
between the mediai and middie cuneiforms, and exited between the mediai cuneiform and the navicular. This created a compietely unsta-
ble mediai coiumn. in this case, the mediai cuneiform shouid aiso be secured with a screw to the middie cuneiform and the navicuiar.

done with small rongeurs, curets, and expose subchondral bone. faces, as saw cuts might shorten
and small osteotomes. The goal It is not necessary or advisable the metatarsals and cuneiforms,
is only to remove the cartilage to use a saw to prepare the sur- which is not of any benefit.
The first tarsometatarsal
joint is about 30 mm deep. In
CRITICAL CONCEPTS I contnueû
the absence of full, broad expo-
AUTHOR UPDATE: i sure of the depth of the joint,
Even though the data support the use of a primary fusion for mainly liga- there is a tendency to fuse it in
mentous disruptions, one shouid not use this technique too liberaity for aii dorsiflexion'. A small lamina
Lisfranc injuries. An exampie of an injury for which the technique is inappro- spreader is very helpful to allow
priate is the hyper-plantar fiexion injury through the Lisfranc joint seen in
full visualization of the entire
footbaii piayers. With this mechanism, there is often a partiai or complete
disruption of the dorsal structures, but the strong plantar ligaments are typi-
joint (Fig. 5).
cally intact. If there is not muitidirectional instability with manipulation, a After complete removal of
fusion should not be done. Patients with this iess severe injury will do rea- the cartilage, the surfaces are pre-
sonably well with conventionai open reduction and internai fixation. pared for fusion by feathering
Since our original paper was published, no substantial changes have been them with a small osteotome. The
made in the surgical technique. screw configuration is usually ex-
actly the same as described above,

l o i KNAI. Ol BONE & lOlNT SDUGERY • SURGICAL TECHNIQUES
The I«! Tarso-metatarsal joint
is 30 mm deep
The superficial peroneal nerve has to be protected throughout the procedure. Adequate
exposure is very important to allow all of the cartilage to be removed from the entire first
tarsometatarsal joint. This can be facilitated by the use of a lamina spreader.
but the screws are always applied
in a compression fashion.
After stabilization of the me-
dial two rays, the stability of the
lliird, 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 re-
duced under fluoroscopy and sta-
bilized with 0.62-mm-diameter
Kirschner wires.
We believe in the liberal use
of a two-incision approach, as ad-
equate exposure of the lateral cor-
127
MARCH 2 0 0 7 • VOLUME 89-A • SUPPLEMENT 2, P A Ü T 1 • IBIS.ORG
Branch of the Superficial
Peroneal Nerve
ner of the second metatarsal base
and the lateral cuneiform can be
very difficult to obtain through a
single dorsomedial incision.
The second incision is cen-
tered over the fourth metatar-
sal. The most common mistake
is to make the incision too far
medial; proper placement of the
incision may be aided by fiuoro-
scopic guidance and identifica-
tion of the intended osseous
targets. The foot should be in-
ternally 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 lat-
eral three metatarsals to accu-
rately determine the position of
the fourth ray.
This lateral incision endan-
gers the lateral branches of the
superficial peroneal nerve, which
should also be protected. The in-
cision is usually just lateral to the
extensor digitorum longus ten-
don, which is easily elevated to
expose the underlying extensor
digitorum brevis. The brevis
muscle belly is divided longitudi-
nally with sharp dissection to al-
low visualization of the third and
fourth tarsomctatarsai joints and
the lateral half of the second tar-
sometatarsal joint.
J. Chris Coetzee, MD, FRCSC
Minnesota Sports Medicine, 775 Prairie Center
Drive. #250. Eden Prairie. MN 55344. E-mail
address: jcc@ocpamn.com
Thuan V. Ly, MD
Department of Orthopaedic Surgery, University of
Minnesota, 2450 Riverside Avenue, R200, Minne-
apolis. MN 55454
doi:10.2106/JBJS,F.01004
REFERENCES
1. Sangeorzan BJ. Veith RG. Hansen ST
Jr. Salvage of Lisfranc's tarsometatarsal
joint by arthrodesis. Foot Ankle. 1990:
10:193-200.
2. Coetzee JC, Resig SG, Kuskowski M,
Saleh KJ. The Lapidus procedure as salvage
after failed surgical treatment of hallux val-
gus. Surgical technique. J Bone Joint Surg
Am. 2004:86 SuppI 1:30-6.
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