Lecture 44 shah delayed lisfranc
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Similaire à Lecture 44 shah delayed lisfranc
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Lecture 44 shah delayed lisfranc
- 1. • Young adult with polytrauma • Ipsilateral fracture dislocation hip • Ipsilateral comminuted fracture upper end tibia • Open Fracture contralateral tibia • WITH…. In most advanced trauma centre…
- 2. Missed lisfranc: now what? Dr Rajiv Shah ‘Foot & Ankle orthopaedics’ Foot & Ankle Surgeon President, Indian Foot & Ankle Society
- 3. 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
- 4. Midfoot arthritis: Chronic foot pain Functional disability Guidelines lacking To rigid on push off
- 5. Midfoot Arthritis: Diagnosis • Pain • Tenderness • Deformity – Loss of Arch – Midfoot Abduction • Gait Abnormality – Non Rigid Arch During Push-Off
- 6. Physical Exam • N/V status • Skin condition • Palpate joints • Assess alignment – Pes planus – Abduction
- 7. Physical Exam • Painful motion?
- 8. Radiology • X-Rays – AP,Lateral, & 30o Oblique • Parallel to TMT Joint Surfaces – 15-20o Cephalad – Weight-Bearing • CT Scan
- 9. 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
- 10. Diagnostic or Therapeutic Injections •25-33% accuracy with palpation alone •Must use Fluoro or US •Extravasation of dye in approx. 20%
- 11. Aims of treatment: Pain relief by enhancing stability Fusion in functional position Plantigrade foot
- 12. Non-Op Treatment • NSAID • Activity Modification • Local steroids • Stiff soled shoes • Rocker soled shoes • Full length steel shank • Orthotics: UCBL, hinged AFO • Carbon footplates
- 13. Non-op treatment • Carbon footplate Carbon Footplate 70% pain reduction Steel shank shoe
- 14. Conservative mx: Carbon foot plate 3Q insert
- 15. 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
- 16. 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
- 17. Operative Principles • K-wire for temporary fixation – Use crossed screws, dorsal plates compression staples dorsal locking plate
- 18. • Stability of the fusion can be improved by plates Tarso MT Joint Midfoot Joints Plating allows for reliable fusion Can Hold corrected deformity Midfoot plus TM Joints
- 20. Dorsiflexion of toes while tightening screws reduces GAP in the joints
- 21. 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
- 22. Case Example • Female aged 33 years • Pain, swelling & inability to ambulate • 4.5 months post trauma
- 24. Original X-ray
- 25. At surgery….
- 26. Case example:
- 27. Case example:
- 28. Case example: 1st -3rd TMT fusion Isolated 2nd fusion
- 29. 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
- 30. That’s all… Thank you all..