How is surgery performed for the treatment of Lisfranc fracture dislocation?

Updated: Apr 20, 2020
  • Author: Nirmal Tejwani, MD, MPA; Chief Editor: Thomas M DeBerardino, MD  more...
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Answer

Often, surgery should be delayed until excessive swelling has resolved. Swelling places the soft tissues at risk. Supine position with a thigh or ankle tourniquet is recommended. Be aware of and ready to address all injuries present before beginning the surgical procedure.

A two-incision approach works best for complete visualization. The medial incision is in line with the first webspace. The branches of the superficial peroneal nerve are identified and protected. The muscle belly of the extensor hallucis brevis covers the neurovascular bundle. Identify and protect the deep peroneal nerve, dorsalis pedis artery, and extensor tendons. Once the area of the second TMT joint is reached, perform subperiosteal dissection across the Lisfranc joint to minimize damage to soft-tissue structures.

If needed, a second incision is based over the lateral border of the third MT and is carried distally. The extensor digitorum brevis is divided bluntly, and the TMTs are entered subperiosteally. In this region, the third and fourth TMT joints literally are one on top of the other and are easily visualized.

With the tarsus stabilized and the joints inspected, reduction can be carried out with gentle pressure and manipulation. The author finds it easiest to reduce the medial column first by placing a provisional wire across the first TMT joint and, if necessary, a provisional wire between the first and second cuneiforms. If acceptable reduction is achieved, appropriate MT-to-cuneiform screws are then placed.

The second part of the procedure is connecting the medial and middle columns. A screw is placed across the medial cuneiform to the base of the second MT so as to reduce the Lisfranc diastasis. Other authors suggest starting with the second MT–to–medial cuneiform fixation. A large, pointed bone-reduction clamp can be used to hold the reduction while screws are placed. [44] (See the images below.)

Postoperative lateral radiograph illustrates place Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.
Postoperative anteroposterior radiograph demonstra Postoperative anteroposterior radiograph demonstrates fixation of the metatarsal, as well as stabilization of the Lisfranc joint.

An additional screw may be placed from the medial cuneiform to the middle cuneiform to complete the "box" with screws from the first and second MTs to their respective cuneiforms and the Lisfranc screw.

Because no real tissue layers are present at this level of the foot, wound closure can be accomplished with an absorbable suture to close joint capsules and a nonabsorbable suture in using a vertical or horizontal mattress technique to close the skin.


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