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 cold therapy / kodiak cold therapy / game ready cold therapy
- Assess with AOFAS midfoot scale

0 - 3 WEEKS:

- Patient immobilized in a short leg cast and can mobilize using crutches or Knee Walker - USA / Knee Walker - Canada
- Non-weight bearing
- Keep cast clean and dry / Cast protector - USA / Cast protector - Canada
- Leg elevation for edema control
- Staple / suture removal and wound check at 3 weeks post-op.

3 - 12 WEEKS:

- Can weight bear on heel in short cast boot
- Start physiotherapy
- Can use cold therapy unit
- 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
- Wean off crutches / cane / cast 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 - at 2 weeks post-op.

Friday, 13 September 2013

Lisfranc Fracture Club

The Lisfranc Fracture Club on facebook 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 / decision making process

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 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, 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) Non-operative management has been exhausted.  Approximately 30% of patients referred for a Lisfranc injury do well with non-operative management.

5) You can take the time to find an Orthopaedic Surgeon who specializes in Foot and Ankle Surgery to perform your surgery.  This is especially true if you proceed with a Lisfranc fusion procedure.  A Lisfranc fusion procedure is a surprisingly technical operation that is difficult to perform well.

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.

Sunday, 14 July 2013

Tibial plafond - pre and post-op x-ray montage

Some recent cases completed at Georgetown Hospital:

Case 1:


Case 2:


Case 3:


Case 4:


Case 5:


Case 6:


Case 7:



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 and transitioned to a hard sole shoe / hiking boot as pain and swelling decreased.  The average time was between 6 to 12 weeks.

Some patients had no pain after the injury had healed, others had minimal pain and decided that surgery + the associated recovery time was not in their best interest.

Case 1:


Case 2:


Case 3:


Case 4:


Case 5:


Case 6:


Case 7:


Case 8:


Case 9:


Case 10:


Case 11:


Case 12:


Case 12 - patient had evident lisfranc injury on right side.  Patient was transitioned from a cast boot to a hard soled shoe.  At 9 weeks patient no longer had pain and was able to perform a single heel raise.  As such we opted not to proceed with a lisfranc fusion procedure.

Case 13:


Case 14:


Case 15:


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