Saturday, 26 July 2014

Georgetown Accelerated Post-op Lisfranc Fusion Protocol

Dr. Christopher Lu MBchB FRCSC / Darryl Yardley M.Sc.PT / Niyati Shah M.Sc RS
Lisfranc fusion post-op protocol

PRE-OPERATIVE PHYSIOTHERAPY:

- Gait training, advice on edema control and pain managment / cryocuff
- Assess with AOFAS midfoot scale

0 - 3 WEEKS:

- Patient immobilized in cast boot and can mobilize using crutches
- May weight-bear on heel
- Leg elevation + cryocuff / ice for edema control / may remove boot for cryocuff application or when sleeping and at rest.
- If dressing is leaking, reinforce dressing / apply pressure / Do your best to keep the wound clean and dry.
- Staple / suture removal and wound check at 3 weeks post-op.

3 - 12 WEEKS:

- Start physiotherapy
- Active ankle ROM in pain free range
- Include dorsiflexion, plantar flexion, inversion and eversion
- Ankle circles
- Ankle alphabets (trace alphabet in air with foot)
- Proprioception non-weight bearing exercises / kinesthetic awareness
- Wiggle toes / toe stretches / pick up marbles with toes
- Straight leg lifts + side lifts / non-weight bearing strengthening exercises
- Stationary recumbent bike with more work on weight bearing extremity / use cast boot initially for 1st week / gradually ween out of boot
- Passive ROM - rear foot mainly, soft tissue work on tibialis anterior / peroneals / FHL / EHL / tibialis posterior
- RMT for swelling and scar tissue mobilization when wounds have healed
- TENS, IFC, NMES, hydrotherapy, wax therapy and ice as needed.
- Isometric (hold / relax ankle movements) can start at 10 weeks post-op

3 - 6 MONTHS:

- Patient now full weight bearing
- Gait retraining
- Get rid of crutches and boot / resume normal walking
- Ankle ROM with weights
- Weight bearing proprioception exercises
- Theraband ankle movements
- Heel-toe raises
- Active calf stretch and active tibialis anterior stretch
- Lunges / Stepping - ensure patient has pain free weight acceptance on affected side.
- Passive ROM to improve ROM
- Modalities as need, RMT as needed

6 MONTHS +:
- Running if tolerated and done before surgery / Treadmill

Discharge with full ROM and ankle / foot muscle strength 4+ /5 / Pain free movements

Assess with AOFAS midfoot scale at 6 weeks, 12 weeks, 6 months and 12 months.

Disclaimer:  This physiotherapy protocol is specifically designed for patients who have had their Lisfranc fusion performed at Georgetown Hospital.  We routinely perform our fusion using a locking plate + screw construct instead of screws alone.  This provides a more rigid construct.  As such, we initially immobilize patients in a boot instead of a cast and allow early heel weight bearing.

Friday, 13 September 2013

Lisfranc Fracture Club

The Lisfranc Fracture Club on facebook via Vipin requested that I make a more prominent post for them.

Please see link below:

https://www.facebook.com/LisfrancFractureClub


Monday, 15 July 2013

Lisfranc injury - internet resources

Below is a list of other internet resources worth reading if you have a lisfranc injury:

http://orthoinfo.aaos.org/topic.cfm?topic=A00162

http://www.aafp.org/afp/1998/0701/p118.html

http://www.orthobullets.com/foot-and-ankle/7030/lisfranc-injury-tarsometatarsal-fracture-dislocation

http://emedicine.medscape.com/article/1236228-overview

One advantage of fusion vs. ORIF is that the procedure no longer needs to be performed urgently.
A fusion can be performed at almost anytime after the injury.  One caveat is the severity of the injury.  Another caveat is that patients who wait greater than 1 year - seem to have a worse outcome.  At present, the optimal time to perform surgery seems to be within 3 months of injury.

This is good for several reasons:

1) The patient can plan when they want to have the fusion.  This gives the patient time to plan ahead in regards to work, child care, transportation and housing arrangements.

2) The patient and surgeon are convinced that they are dealing with a true lisfranc injury.  If you have a simple metatarsal fracture this should heal within 6 to 12 weeks.  However, if the pain does not get better in this time period, and you have separation at the lisfranc ligament, there is a possibility that you have a lisfranc injury.

3) Swelling in the foot and wound closure is no longer an issue.

4) You can take the time to find an Orthopaedic Surgeon who specializes in Foot and Ankle Surgery to perform your surgery.

Saturday, 6 July 2013

Lisfranc fusion - pre and post-op x-ray montage / Lisfranc and Ligamentous Lisfranc injuries

Some recent cases completed at Georgetown Hospital:

Case 1:


Case 2:

Ligamentous lisfranc injury


Case 3:


Case 4:


Case 5:


Case 5.1:

Patient requested removal of hardware



Case 6:


Case 7:


Case 8:


Case 9:


Case 9.1:

Patient did not achieve fusion / broken plate / required revision fusion:


Case 10:


Case 11:


Case 12:


Case 13:


3rd metatarsal required further hardware to obtain reduction.


Case 14:

Ligamentous lisfranc injury


Case 15:

Pre-op bilateral foot AP weight bearing x-ray / Patient had pain in foot for 9 month before deciding to proceed with surgery.

Ligamentous lisfranc injury



Case 16:

Pre-op bilateral foot AP weight bearing x-ray / Patient had pain in foot for 1 year before deciding to proceed with surgery.



Case 17:


Case 18:


Case 19:


Case 20:







Tuesday, 4 June 2013

The grave of Dr. Jacques Lisfranc


Somewhat morbid, but above is a picture of Dr. Lisfranc's grave.

He is buried at the Montparnasse Cemetery in Paris.

Lisfranc Grave Link

Friday, 24 May 2013

Lisfranc Injuries in the NFL

Below is an interesting article on Lisfranc injuries in the NFL.

They appear to be a career limiting injury.

Lisfranc Injuries in the NFL - Link to article

Tuesday, 14 May 2013

Non-operative Management

Cases treated non-operatively.

These are patients who opted not to proceed with surgery.  As you can see all had x-ray findings consistent with a lisfranc injury.  They were allowed to be weight bearing as tolerated in a cast boot.

Case 1:


Case 2:


Case 3:


Case 4:


Case 5:


Case 6:


Case 7:


Case 8:


Case 9:


Case 10:


Case 11:


Case 11 - reinforces the need to obtain bilateral AP standing x-rays.  In this case the patient had fractures of the base of the 2nd, 3rd and 4th metatarsals.  These healed uneventfully - patient was pain free at 12 weeks.  Separation between the base of 1st and 2nd metatarsal was a normal anatomic variant in this patient.

Case 12:


Sunday, 28 April 2013

Tracking Outcomes - AOFAS Midfoot Scale

In an effort to track outcomes for our patients we will be using the AOFAS midfoot scale.  I have attached the AOFAS midfoot scoring sheet.  If you are a patient it would be appreciated if you could fill out this form on your first and subsequent visits.

AOFAS Midfoot Scale - PDF File


Thursday, 18 April 2013

Lisfranc Fusion Video

Although this linked video was produced specifically for hallux valgus surgery, the principles are the same and good surgical technique is demonstrated.



Wednesday, 17 April 2013

Ligamentous Lisfranc Injuries

Ligamentous Lisfranc Injuries are often associated with poor outcomes.  I have attached pre and post operative x-rays of a Lisfranc fusion.

Pre-operative Bilateral Standing X-rays

Post-operative AP
Post-operative Lateral

Tuesday, 16 April 2013

Lisfranc Injuries

Lisfranc injuries are rare.  They account for 0.2% of all fractures.  This works out to an incidence of 1 per 55,000 persons per year.  In the Greater Toronto Area - we have a population of 5.5 million.  Therefore there are approximately 100 Lisfranc injuries per year in the GTA.  There are approximately 200 Orthopaedic Surgeons in the GTA.  Therefore each surgeon on average, will see one Lisfranc injury every 2 years.

If you are reading this blog there is a good chance that either you or someone you know has a Lisfranc injury.  Alternatively, you are probably an Orthopaedic Surgery Resident or Attending.

I have a sub-specialty interest in Lisfranc injuries and have created a regional centre of excellence for the treatment of patients with Lisfranc injuries.  If you have a Lisfranc injury and happen to live in Canada simply have your Family Physician / Orthopaedic Surgeon fax a referral to our office. International patients are asked to contact our office for further information / pre-clearance.

Surgery is performed at Georgetown Hospital, which is located 30 minutes from Toronto Pearson Airport.  Lisfranc fusion procedures are performed as a day surgery procedure.  We routinely use a local anaethetic block and sedation as our mode of anaesthetic.  Operative time is approximately 70 minutes.

Preferred work up for patients would be: Bilateral standing x-rays and a CT of the affected foot.

Assuming that you are a non-smoker / non-diabetic there is an 80% chance that we can achieve an improved outcome with a Lisfranc fusion procedure.  However, I am limited in that I cannot make your foot better than the uninjured side.

If you have a Lisfranc injury and are interested in reconstructive surgery please have your Family Physician / Sports Medicine Physician / Orthopaedic Surgeon refer you to:

Dr. Christopher Lu MBchB FRCSC
Assistant Clinical Professor (Adjunct) - McMaster University
Orthopaedic Lisfranc Surgeon
Unit 200 - 1A Princess Anne Drive
Georgetown, Ontario
Canada
L7G 4W4

Linkedin profile:

http://www.linkedin.com/in/chrisluortho

Phone: 905-873-8883
Fax: 289-801-2239

Monday, 15 April 2013

Lisfranc Video Summary

I have attached a great summary video produced by Dr. Nabil Ebraheim.


Saturday, 13 April 2013

Lisfranc ORIF vs. Fusion

A 2012 article comparing Lisfranc ORIF vs. Fusion.

Below I have also listed the other comparative studies that have been performed.

Lisfranc ORIF vs. Fusion 2012 - pdf

Lisfranc ORIF vs. Fusion 2009

Lisfranc ORIF vs. Fusion 2006

One advantage of fusion vs. ORIF is that the procedure no longer needs to be performed urgently. One caveat is the severity of the injury.  Another caveat is that patients who wait greater than 1 year - seem to have a worse outcome.  At present, the optimal time to perform surgery seems to be within 4 months of injury.

This is good for several reasons:

1) The patient can plan when they want to have the fusion.  This gives the patient time to plan ahead in regards to work, school, child care, transportation and housing arrangements.

2) The patient and surgeon are convinced that they are dealing with a true lisfranc injury.  If you have a simple metatarsal fracture this should heal within 6 to 12 weeks.  However, if the pain does not get better in this time period, and you have separation at the lisfranc ligament, there is a possibility that you have a lisfranc injury.  The recovery from any lisfranc procedure is a minimum of 6 months (typically 1 year), thus it is important to ensure you are dealing with a true lisfranc injury with the associated chronic pain before choosing surgical treatment.

3) Swelling in the foot and wound closure is no longer an issue.

4) You can take the time to find an Orthopaedic Surgeon who specializes in Foot and Ankle Surgery to perform your surgery.  If you decide to proceed with a fusion procedure I would recommend that you find an Orthopaedic Surgeon who specializes in Foot and Ankle Surgery.

5) Based on the articles listed above and personal experience, lisfranc fusion patients tend to have consistently better results at short and mid term follow-up.

6) If a fusion procedure is successful - no further operations are required.  With ORIF, it is often routine to remove the hardware.  Also, if the ORIF is not successful, the next option is to proceed with hardware removal, followed by a fusion procedure.  Unfortunately, at this point the patient is usually several years into their injury and have developed chronic pain.

Medical Disclaimer
The medical and healthcare information on this site is intended as an information resource only and does not create any patient-physician relationship, and should not be used as a substitute for professional diagnosis and treatment.