LISFRANC Joint Surgery information timeline and summary management
Open reduction with internal fixation (ORIF) via screws, plate or tightrope are some of the current procedures available to surgeons for stabilisation of this injury
The Lisfranc joints are located in the midfoot they are the tarsometatarsal joints (TMTJs). The main indication for this ORIF of the Lisfranc joints is a displaced or unstable Lisfranc fracture or a dislocation. This can be seen best on a Wbg or PWBg Xray. The purpose of the surgery is to reposition the bones and joints in the mid-part of the foot, allowing the associated torn ligaments (the strong tissues that hold these bones together and support the arch) to heal. In order to treat some injuries, mid-foot fusion may be recommended where some of the joints are permanently placed together.
The location of the incision is dictated by both the location of the fracture and the location of the joints that are disrupted. If all five of the Lisfranc joints are disrupted, then two or three incisions on the top of the foot may be needed; one on the top inside and inside border of the foot, and one on the top outside of the foot.
Once the disrupted tarsometatarsal joints are identified, the dissection is carried down to the involved joints and the debris is cleaned out.
The disrupted joints are positioned back to the position they were in prior to the injury.
The joints are then fixed with screws, plates with screws, suture based implants, and/or pins. Depending upon the type of injury and time when being fixed, some joints may need to be put together permanently (fusion). One exception is a disruption of the 4th and 5th tarsometatarsal joints; in this case, the bone is provisionally fixed with wires. The wires are then removed after about six weeks so that some movement of these joints can be encouraged. Regaining flexibility of the outside joints of the foot is important for walking.
Example Timeline for Recovery
Recovery from surgery to fix a Lisfranc fracture, subluxation, or dislocation can vary depending on the severity of the original injury, and the stability of the fixation.
A displaced injury takes a number of months (6-9) of recovery. You will need an experienced therapist to help guide you through the rehabilitation of this injury at least twice per week.
For most Lisfranc injuries, about 70% of the recovery occurs in the first 6 months, but it is often a year or more before a patient has reached their point of maximal improvement following a significant Lisfranc injury.
If fixed with plates and screws, some patients (not suitable for all) may require removal of the hardware to help regain motion of the joints. This is something that will be discussed at your review appointment with your surgeon. However, a typical recovery with one of our experienced therapists may include:
Week 1: Non-Wbg • The patient is non-weight bearing to allow for adequate healing of the bones and of the disrupted ligaments. The ligaments actually require a longer time to heal. (12wks) • Crutches and walker boot required or a scooter for mobility • Boot on for sleeping • Oedema management • POLICE • Pain management • Wound management • Begin accelerated rehab of passive ankle and toe movements • Measure Ankle / foot / toe ROMs • Soft tissue management and tone management of all lower leg compartments • Maintain strength and ROM of other body parts Week 2 - Non-Wbg • Stitches are removed bw 10-14days (all non absorb and the wings off the absorbable sutures are removed) • Fixomul skin tape and steri strips applied • Oedema management • Pain management • Wound and scar management • POLICE • Maintain Passive ROM of ankle foot toes • Level 1 Active strengthening of forefoot and ankle • Soft tissue management and tone management of all lower leg compartments • Maintain strength and ROM of other body parts • Boot on for all of the time and still on for sleeping (only remove boot for passive and active strengthening) Week 3 - Non-Wbg • Oedema management • Pain management • Wound and scar management • POLICE • Maintain Passive ROM of ankle, foot and toes • Level 2 Active strengthening of forefoot and ankle • Soft tissue management and tone management of all lower leg compartments • Maintain strength and ROM of other body parts • Boot on for all of the time and still on for sleeping (only remove boot for passive and active strengthening) Week 4 - Non-Wbg • Oedema management • Pain management • Wound and scar management and desensitisation • POLICE • Maintain Passive ROM of ankle foot toes • Level 2 Active strengthening of forefoot and ankle • Soft tissue management and tone management of all lower leg compartments • Maintain strength and ROM of other body parts • Boot on for all of the time and still on for sleeping (only remove boot for passive and active strengthening) Week 5 - Non-Wbg • Oedema management • Pain management • Wound and scar management and desensitisation • POLICE • Maintain Passive ROM of ankle, foot and toes • Level 3 Active strengthening of forefoot and ankle • Soft tissue management and tone management of all lower leg compartments • Maintain strength and ROM of other body parts • Boot on for all mobilisation and on for sleeping, remove boot when you can Week 6 - Non-Wbg • Oedema management • Pain management • scar management and desensitisation • POLICE • Maintain Passive ROM of ankle, foot and toes • Level 3 Active strengthening of forefoot and ankle • Soft tissue management and tone management of all lower leg compartments • Maintain strength and ROM of other body parts • Boot on for all mobilisation and on for sleeping, remove boot when you can
Review appointment at the end of 6 weeks with surgeon with X-rays to check for healing of injury Week 7 (or 8) – 10 (or 14) weeks Post-Surgery
• The patient can begin to weight-bear as tolerated, provided the foot is protected in a walking boot, such as a CAM walker. This boot (characterized by a rigid sole a rocker-bottom contour) serves to disperse the force away from the middle of the foot and up the leg
• Wound and scar management
• POLICE
• Maintain Passive ROM of ankle, foot and toes
• Level 4 Active strengthening of forefoot and ankle
• Soft tissue management and tone management of all lower leg compartments
• Maintain strength and ROM of other body parts
• Orthotic therapy
• Footwear decisions once foot can fit back into normal shoes
Week 10-14
• Scar management
• POLICE
• Maintain Passive ROM of ankle, foot and toes
• Level 5 Active strengthening of forefoot and ankle
• Soft tissue management and tone management of all lower leg compartments
• Maintain strength and ROM of foot and other body parts
• Orthotic therapy
• Footwear decisions once foot can fit back into normal shoes - At the 10-14 week mark, the patient can then transition into a stiff soled shoe.
• ADL reviewed (ability to balance, walk, squat, uneven terrain and cambers)
• Work place review
Week 15-26
• ADL progressions
• Scar tissue management
• POLICE
• Maintain Passive ROM of ankle, foot and toes
• Level 5 Active strengthening of forefoot and ankle
• Soft tissue management and tone management of all lower leg compartments
• Maintain strength and ROM foot and of other body parts
• ADL reviewed (ability to balance, walk, squat, uneven terrain and cambers)
• Work place review
Potential General Complications
• Asymmetric Gait (leading to pain elsewhere)
• Deep Vein Thrombosis (Blood Clot)
• Failure to Resolve ALL Symptoms
• Continued and sometimes altered foot pain
Potential Specific Complications
• Nerve Injury. Injury to the nerves between the 1st and 2nd metatarsals (deep peroneal nerve), and on the top inside aspect of the 1st metatarsal (medial branch of the superficial peroneal nerve), can occur due to the placement of the incisions. Nerve injury can occur due to retraction, direct injury, or from scarring during the recovery process. If these nerves are injured or cut, the patient could end up with numbness or pain along the path of the nerve.
• Broken Hardware. Although screws are inserted to help stabilize the joints in an ORIF, they are not fused together. Movement is encouraged through the healing process, and the incorporated screws may have a potential to break. Although removal of the screws may be necessary, judgment is critical since removal of the screws will weaken the midfoot. In the setting of a Lisfranc injury treated by fusion, the hardware typically is not removed unless symptomatic.
• Midfoot Collapse. Related to the complication of broken hardware prior to adequate healing or incompletely treated injuries, the weakened midfoot has the potential to collapse through the tarsometatarsal joint leading to usually loss of the arch.
• Painful Hardware. Pain may be associated with the screws that are used to secure the joints. This occurrence is much higher in a Lisfranc injury because the hardware has a higher tendency to be more prominent than other parts of the foot.
6 views0 comments