import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Runs between 1st and 2nd metatarsals, only 0-5mm deep to skin in medial incision. **Protection**: Identify EARLY beneath EHB muscle; vessel loop; gentle retraction; injury causes foot ischemia requiring immediate vascular repair **Location**: Accompanies dorsalis pedis artery between MT1-MT2. **Protection**: Identify with artery; gentle retraction; injury causes 1st web space numbness (usually temporary neuropraxia if retraction-related) **Location**: Cross dorsum of foot superficially; intermediate and medial dorsal cutaneous branches at risk in both incisions. **Protection**: Careful subcutaneous dissection; loupe magnification; retract gently; avoid transection **Location**: Between medial incision (MT1-MT2) and lateral incision (MT4). **Protection**: MINIMUM 5-7cm bridge; monitor for ischemia intraoperatively and postoperatively; necrosis may require flap coverage **Location**: Deep to abductor hallucis on plantar-medial midfoot. **Protection**: Avoid plantar dissection; if plantar approach needed, identify and protect; injury causes medial plantar numbness and intrinsic weakness **Patient Position**: Supine with bump under ipsilateral hip (15-20 degrees rotation), radiolucent table, thigh tourniquet (280-320mmHg), foot at end of table or on radiolucent triangle for fluoroscopy access **Surgical Approach**: TWO DORSAL LONGITUDINAL INCISIONS: (1) Medial incision between 1st and 2nd metatarsals (8-10cm) exposing medial and middle columns (1st, 2nd, 3rd TMT joints), (2) Lateral incision over 4th metatarsal (6-8cm) exposing lateral column (4th and 5th TMT joints). Preserve skin bridge minimum 5-7cm to prevent necrosis. **Incision**: Dual dorsal longitudinal incisions: (1) 8-10cm between MT1-MT2 for medial/middle columns, (2) 6-8cm over MT4 for lateral column, preserve 5-7cm skin bridge ### Myerson Classification | Type | Description | Pattern | Treatment Implications | |------|-------------|---------|----------------------| | **Type A** | Total incongruity | All 5 TMT joints displaced in same direction | Usually lateral or dorsolateral; severe injury; full exposure needed | | **Type B1** | Partial incongruity - Medial | Medial column displaced, lateral column stable | Medial incision only may suffice | | **Type B2** | Partial incongruity - Lateral | Lateral column displaced, medial column stable | Less common; may need single lateral incision | | **Type C** | Divergent | Medial and lateral columns displaced in opposite directions | Most severe; 1st MT medial, 2nd-5th lateral; dual incisions required | **Clinical Pearl:** Type C (divergent) is associated with highest energy, most severe soft tissue injury, and worst outcomes. ### Critical Anatomy **Lisfranc Ligament:** - Runs from medial cuneiform (C1) PLANTAR surface to 2nd metatarsal base - Strongest interosseous ligament of midfoot - NO direct ligament connects MT1 to MT2 - this explains 1st-2nd diastasis **Three Columns:** - **Medial column**: 1st TMT (most mobile, 10-15° sagittal motion) - **Middle column**: 2nd and 3rd TMT (keystone - most rigid, least mobile) - **Lateral column**: 4th and 5th TMT (mobile, important for gait) **Keystone Concept:** - 2nd MT base recessed proximally between cuneiforms - Forms "mortise" analogous to ankle joint - Most commonly injured, most important to reduce anatomically ### Fixation Controversies **1. TRANSARTICULAR SCREWS (Traditional):** - 3.5-4.0mm cortical screws from MT base → cuneiform - Crosses joint, requires removal at 4-6 months - Pro: Strong fixation, familiar technique - Con: Joint penetration, mandatory second surgery **2. DORSAL PLATES (Increasingly Popular):** - Low-profile locking plates span TMT joint dorsally - Extra-articular, preserves joint surface - Pro: No removal needed, joint protection - Con: Hardware prominence on thin dorsum **3. PRIMARY ARTHRODESIS (Emerging Evidence):** - For purely LIGAMENTOUS injuries - Fuse 2nd and 3rd TMT (already minimal motion) - Preserve 1st TMT (10-15° motion important) - Pro: Lower secondary surgery rate, no hardware removal - Con: Irreversible, removes motion from joints **Evidence Summary:** Henning et al. (2009), Ly & Coetzee (2006) showed primary fusion equivalent or superior outcomes for ligamentous Lisfranc. ### Radiographic Criteria for Anatomic Reduction **AP View:** - Medial border MT2 aligns with medial border intermediate cuneiform - 1st-2nd intermetatarsal space <2mm (normal) - Medial border MT4 aligns with medial border cuboid **Oblique View:** - Medial border MT3 aligns with medial border lateral cuneiform - Lateral border MT1 aligns with lateral border medial cuneiform **Lateral View:** - No dorsal subluxation of metatarsal bases - Meary's line (talus-1st MT axis) straight **CRITICAL:** <2mm residual displacement on ALL views. Even 2-3mm associated with poor outcomes and accelerated arthritis. ### When to Consider Primary Fusion **INDICATIONS:** - Purely ligamentous injury (no fractures, only soft tissue disruption) - Significant cartilage damage seen intraoperatively - Failed ORIF with persistent instability - Patient preference (avoid second surgery for screw removal) **CONTRAINDICATIONS:** - Primarily bony injury (fracture-dislocations) - Young high-demand athlete (may prefer attempt at motion preservation) - Inadequate bone stock for fusion **TECHNIQUE:** - Prepare joint surfaces (curette cartilage to subchondral bone) - Autograft (local bone from resection) - Rigid fixation (3.5mm screws, plates, or staples) - Fuse 2nd and 3rd TMT; preserve 1st and 4th/5th if stable **OUTCOMES:** - Multiple studies show equal or better functional outcomes vs ORIF for ligamentous injuries - Lower secondary surgery rate (no hardware removal, fewer salvage fusions) - Earlier return to full weight-bearing ### Step 1: Exposure and assessment - medial column (1st-2nd-3rd TMT) Exposure and assessment - medial column (1st-2nd-3rd TMT): Longitudinal incision between 1st and 2nd metatarsals (8-10cm), centered over TMT joint level. Incise skin and subcutaneous tissue carefully - DORSALIS PEDIS ARTERY AND DEEP PERONEAL NERVE run immediately beneath in this space. Identify and elevate extensor hallucis brevis muscle belly (covers neurovascular structures). Identify dorsalis pedis artery and deep peroneal nerve, place vessel loops for protection, gentle retraction. Expose 1st, 2nd, and 3rd TMT joints subperiosteally. Assess fracture pattern, joint displacement, cartilage damage, soft tissue interposition. **Technical Tip**: EXAM KEY: DORSALIS PEDIS ARTERY between MT1-MT2 is HIGHEST RISK structure - injury causes foot ischemia requiring immediate vascular surgery. Artery typically 0-5mm deep to skin, covered only by thin EHB muscle. CRITICAL to identify early, use vessel loops, protect throughout. Deep peroneal nerve runs with artery, injury causes 1st web space numbness. Examine joint surfaces for cartilage damage - extensive damage may favor primary fusion over ORIF. Remove soft tissue interposition (capsule, tendons) to allow reduction. - Skin necrosis from excessive tension - Damage to underlying structures ### Step 2: Reduction sequence - 1st TMT joint (medial column first) Reduction sequence - 1st TMT joint (medial column first): Begin with 1st TMT joint (medial cuneiform to 1st metatarsal base). Remove debris and hematoma from joint. Use bone clamps or K-wires to reduce joint anatomically. Confirm reduction fluoroscopically - lateral border of MT1 should align with lateral border of medial cuneiform on oblique view. Provisionally stabilize with K-wires. Assess stability - if unstable (purely ligamentous), consider primary fusion vs ORIF based on evidence and patient factors. **Technical Tip**: EXAM KEY: MEDIAL COLUMN FIRST is fundamental principle. 1st TMT joint is foundation - must be anatomically reduced and stabilized before proceeding distally. 1st TMT is mobile joint (10-15 degrees sagittal motion normally) - preservation of motion is goal with ORIF. However, if joint unstable or severe cartilage damage, may consider fusion. Reduction maneuver: longitudinal traction on MT1, direct pressure on base, confirm alignment on fluoroscopy before fixation. - Inadequate reduction - Iatrogenic fracture ### Step 3: Reduction and fixation - 2nd TMT joint (keystone) Reduction and fixation - 2nd TMT joint (keystone): Reduce 2nd TMT joint (intermediate cuneiform to 2nd metatarsal base) - this is the KEYSTONE of Lisfranc joint, recessed proximally. 2nd MT is most commonly injured. Remove debris. Use reduction clamps to restore medial border alignment of MT2 with medial border of C2 (AP view critical). Confirm no diastasis between MT1 and MT2 (<2mm normal). Provisionally stabilize. DECISION POINT: purely ligamentous injury may benefit from primary 2nd TMT fusion based on emerging evidence. Fracture-dislocation proceed with ORIF. **Technical Tip**: EXAM KEY: 2nd TMT is KEYSTONE - recessed proximally forming 'mortise', most rigid, least mobile normally, most commonly injured in Lisfranc. Anatomic reduction critical - medial border MT2 aligns with medial border C2 on AP, no 1st-2nd intermetatarsal diastasis (>2mm abnormal). Lisfranc ligament (C1 to MT2 base plantar) is torn in most injuries - ligament does NOT heal reliably, explains primary fusion debate. Fluoroscopy essential to confirm anatomic reduction before fixation. - Inadequate reduction - Iatrogenic fracture ### Step 4: Fixation options medial and middle columns Fixation options medial and middle columns: FIXATION OPTIONS: (1) TRANSARTICULAR SCREWS: traditional, 3.5mm or 4.0mm cortical screws from MT base to cuneiform, crosses joint, requires removal at 4-6 months to restore motion, risk of articular damage. (2) DORSAL PLATES: extra-articular, spans joint dorsally, avoid cartilage, can remain permanently, growing popularity. (3) PRIMARY FUSION: for purely ligamentous injuries (especially 2nd/3rd TMT), emerging evidence of superior outcomes, avoids hardware removal. Place screws/plates to achieve stable fixation. Confirm no articular penetration fluoroscopically. **Technical Tip**: EXAM KEY: Fixation controversy is high-yield exam topic. TRANSARTICULAR SCREWS: traditional gold standard, 3.5-4.0mm from MT2 to C2, MT3 to C3, ±MT1 to C1 depending on stability. MUST remove at 4-6 months to restore motion (permanent screws cause arthritis). DORSAL PLATES: increasingly used, extra-articular fixation avoiding cartilage, biomechanically stable, no removal needed. PRIMARY FUSION: emerging evidence for LIGAMENTOUS Lisfranc shows equal/better outcomes vs ORIF, fusion of 2nd and 3rd TMT only, preserves 1st and 4th/5th motion. Know evidence and be able to discuss pros/cons of each approach. - Malposition of hardware - Damage to adjacent structures ### Step 5: Lateral column exposure and assessment (4th-5th TMT) Lateral column exposure and assessment (4th-5th TMT): Lateral longitudinal incision over 4th metatarsal (6-8cm), preserving 5-7cm skin bridge from medial incision. Protect superficial peroneal nerve branches. Expose 4th and 5th TMT joints (cuboid to MT4 and MT5). Assess stability - lateral column often stabilizes with medial and middle column reduction due to ligamentous connections. If unstable or displaced, reduce anatomically. Assess fluoroscopically - medial border MT4 aligns with medial border cuboid on AP view. **Technical Tip**: EXAM KEY: Lateral column (4th and 5th TMT) is usually MORE STABLE than medial/middle columns - often reduces indirectly with medial column fixation due to intact intermetatarsal ligaments. May only need K-wire fixation or no fixation if stable after medial/middle column reduction. Over-fixation of lateral column can restrict motion and cause pain. 4th and 5th TMT joints are mobile (important for gait) - preserve motion if possible. Assess stability with gentle stress under fluoroscopy before deciding on fixation. - Skin necrosis from excessive tension - Damage to underlying structures ### Step 6: Final reduction assessment and fixation completion Final reduction assessment and fixation completion: After provisional fixation, perform comprehensive fluoroscopic assessment in AP, oblique, and lateral views. RADIOGRAPHIC CRITERIA: AP view - medial MT2 aligns with medial C2, no 1st-2nd diastasis, medial MT4 aligns with medial cuboid. Oblique view - medial MT3 aligns with medial C3, lateral MT1 aligns with lateral C1. Lateral view - no dorsal displacement, Meary's line straight. GOAL: <2mm residual displacement all joints. If inadequate, remove fixation and re-reduce. Once confirmed, place definitive fixation (screws, plates, or fusion technique). Remove provisional K-wires. **Technical Tip**: EXAM KEY: Anatomic reduction <2mm is CRITICAL for outcomes. Even 2-3mm residual displacement associated with poor outcomes and arthritis. Must confirm on all three views - AP, oblique, lateral. If any view shows >2mm displacement, MUST re-reduce - accept only anatomic reduction. This step separates good from poor outcomes. Examiner wants to see understanding that <2mm is the goal, not 'close enough'. Final stability testing with gentle intraoperative stress confirms secure fixation. - Inadequate reduction - Iatrogenic fracture ### Step 7: Closure and immobilization Closure and immobilization: Irrigate wounds thoroughly. Close in layers - periosteum/capsule if possible (absorbable), deep fascia, subcutaneous to eliminate dead space (minimize over prominent hardware), skin with nylon or staples. Apply sterile dressings. CRITICAL: assess skin bridge between incisions for ischemia. Place well-padded below-knee splint with foot in neutral position (slight plantarflexion acceptable to reduce tension on dorsal soft tissues). Elevate leg strictly for 48-72 hours. Monitor for compartment syndrome signs. **Technical Tip**: EXAM KEY: Wound closure critical - skin over midfoot is tenuous, especially over prominent hardware. May need to modify hardware placement if skin tension excessive. Skin bridge between incisions must be minimum 5-7cm and viable - monitor for ischemia. Strict elevation for 48-72 hours reduces swelling and wound complications. Compartment syndrome risk persists postoperatively - must monitor clinically (pain out of proportion, tense compartments, pain with passive stretch). Low threshold for fasciotomy if suspected - delay causes catastrophic outcomes. - Skin necrosis from excessive tension - Damage to underlying structures ### Step 8: Post-operative protocol and hardware management Post-operative protocol and hardware management: PROTOCOL: Strict non-weight-bearing in below-knee cast or boot for 6-8 weeks. Radiographs at 2, 6, and 12 weeks to monitor alignment and healing. If maintained and fractures healed, progressive weight-bearing in boot weeks 8-12 (25%, 50%, 75%, full). Transition to supportive shoes with arch support orthoses at 12 weeks. HARDWARE REMOVAL: if transarticular screws used, must remove at 4-6 months to restore TMT motion (permanent screws cause arthritis). Plates can remain permanently if asymptomatic. Return to full activities 4-6 months for ADLs, 6-12 months for athletics. **Technical Tip**: EXAM KEY: Non-weight-bearing for 6-8 weeks is essential - early weight-bearing risks loss of reduction and hardware failure. Transarticular screws MUST be removed at 4-6 months - permanent screws across TMT joints cause iatrogenic arthritis (joints need motion). This is major disadvantage of screws vs plates or primary fusion. Patient counseling critical - hardware removal is second surgery. Return to high-level athletics often 6-12 months, and many patients have permanent functional limitation despite anatomic reduction - realistic expectations important. - Malposition of hardware - Damage to adjacent structures ### Step 9: Long-term follow-up and management of arthritis Long-term follow-up and management of arthritis: Long-term follow-up at 6 months, 1 year, then annually. Monitor for development of post-traumatic arthritis (20-50% incidence over 5-10 years). Symptoms: midfoot pain with activity, stiffness, difficulty with uneven ground. Radiographs show joint space narrowing, osteophytes, subchondral sclerosis. Conservative management: orthoses, activity modification, NSAIDs, intra-articular steroid injections. If conservative fails: salvage TMT FUSION of symptomatic joints (2nd and 3rd most common, can preserve 1st and 4th/5th if asymptomatic). Fusion provides pain relief with minimal functional impact (TMT joints have limited motion normally). **Technical Tip**: EXAM KEY: Post-traumatic arthritis is most common long-term complication (20-50%) despite anatomic ORIF. Patient counseling at time of initial surgery should include this risk - Lisfranc is serious injury with high secondary surgery rate. Salvage fusion of symptomatic TMT joints is effective for pain relief - typically fuse 2nd and 3rd TMT (already minimal motion), preserve 1st TMT if possible (10-15 degrees motion important for gait), 4th/5th rarely symptomatic. Fusion outcomes generally good - 80-90% pain relief, minimal functional impact since joints have limited normal motion. This is why primary fusion debate exists - if high fusion rate anyway, why not fuse primarily for ligamentous injuries? - Iatrogenic injury to adjacent structures ### Step 10: Assess for compartment syndrome and document neurovascular status Assess for compartment syndrome and document neurovascular status: Before and after tourniquet release, palpate all foot compartments for tension. Lisfranc injuries, especially high-energy mechanisms, carry significant compartment syndrome risk (5-10%). Classic signs: pain out of proportion, pain with passive stretch of toes, tense compartments, pulselessness (late sign). If suspected, proceed immediately to foot fasciotomy - delay causes permanent damage. Document neurovascular status including dorsalis pedis pulse, posterior tibial pulse, sensation in all nerve distributions. Compare to preoperative status. **Technical Tip**: EXAM KEY: Compartment syndrome is devastating complication if missed. High index of suspicion required, especially with crush mechanism, delayed surgery, or extensive soft tissue injury. Don't be falsely reassured by palpable pulses - they are preserved until very late. Pain out of proportion and pain with passive stretch are early signs. Low threshold for fasciotomy if any concern - better to do an unnecessary fasciotomy than miss compartment syndrome. Nine compartments in foot - medial, lateral, superficial, adductor, four interossei, calcaneal. - Missed compartment syndrome causing permanent disability - Delayed diagnosis requiring amputation in severe cases Strict non-weight-bearing cast/boot 6-8 weeks. Progressive weight-bearing weeks 8-12. Custom orthoses (arch support) at 12 weeks. Hardware removal 4-6 months if transarticular screws. Return to ADLs 4-6 months, athletics 6-12 months. Annual follow-up to monitor for post-traumatic arthritis. Salvage TMT fusion if symptomatic arthritis develops. 1. Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225-242. 2. Ly TV, Coetzee JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. J Bone Joint Surg Am. 2006;88(3):514-520. 3. Henning JA, Jones CB, Sietsema DL, et al. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int. 2009;30(10):913-922. 4. Kuo RS, Tejwani NC, Digiovanni CW, et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am. 2000;82(11):1609-1618. 5. Sands AK, Grose A. Lisfranc injuries. Injury. 2004;35 Suppl 2:SB71-76. 6. Philbin T, Rosenberg G, Sferra JJ. Complications of missed or untreated Lisfranc injuries. Foot Ankle Clin. 2003;8(1):61-71. 7. Mulier T, Reynders P, Dereymaeker G, Broos P. Severe Lisfranc injuries: primary arthrodesis or ORIF? Foot Ankle Int. 2002;23(10):902-905. 8. Arntz CT, Veith RG, Hansen ST Jr. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am. 1988;70(2):173-181. 9. Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br. 1982;64(3):349-356. 10. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878.

ORIF Lisfranc Injury (Tarsometatarsal Fracture-Dislocation)

ORIF Lisfranc Injury (Tarsometatarsal Fracture-Dislocation)