Monday, 2 May 2016

Georgetown Post-op Lisfranc Fusion Protocol 2017

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
- Advice in regards to improving fusion outcomes: stop smoking, decrease alcohol intake, ensure adequate amounts of vitamin D drops (2000 u / day) + calcium in diet, use of bone stimulator
- Purchase: crutches, knee walker, cast protector
- Assess with AOFAS midfoot scale
- If you are interested in pre-operative physiotherapy and a pain management consult please call 
Restore Physiotherapy Georgetown - 905-702-1840
- This rehab protocol has been designed to minimize potential complications.
0 - 6 WEEKS:

- Patient immobilized in a short leg cast and can mobilize using crutches / knee scooter / iwalk 2.0

- Use cold therapy for pain relief
- Non-weight bearing
- Keep cast clean and dry
- Leg elevation for edema control
- Can take aspirin 81 mg, once a day while immobilized in cast - for DVT prophylaxis - if there are no contraindications / allergies.
- Staple / suture removal and wound check at 3 weeks post-op.
- Change to new short leg cast after suture removal.

6 - 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
- Trial of HOKA one running shoes
- Fitting for custom orthotics

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 allow early heel weight bearing.

Sunday, 1 May 2016

Recommended Aids to help with post-op recovery

1) Breg Kodiak Cold Therapy + Ankle / Foot Attachment / Game Ready / Ossur



Review:

Cold therapy has been the biggest change in my practice over the past 2 years.  Foot surgery is generally painful and uncomfortable.  Swelling tends to pool to the lowest point due to gravity.  Unfortunately, this point is your foot.  The worst pain occurs in the first 2 days, the first 2 weeks are quite painful, and you will slowly notice improvement in the pain after 2 weeks post-op.  Cold therapy has significantly decreased the amount of pain medication that I routinely prescribe.  

US Amazon Link:


2) Walking Aids - Crutches / Knee Scooter / iWalk 2.0


Review:

Crutches are not easy to use.  You need good upper body strength and balance.  If you have a lisfranc / midfoot fusion you will be off your foot for 6 weeks.  A significant number of my patients have injured themselves while using crutches.

If you are worried about your mobility and want the safest option to mobilize, please consider the purchase of a knee walker scooter.  They are generally quite safe and easy to use.

If you want something more adventurous - you have the option of using an iWalk 2.0.
Personally, the iWalk gave me a cramp in my calf and it was not for me.  However, some of my patients love this device.

In general, I recommend scheduling a pre-op visit with the physiotherapist.  You can try each of the devices and pick the one that is right for you.

US Amazon Link:

Crutches
Knee Scooter
iWalk 2.0

Canada Amazon Link:

Crutches
Knee Scooter
iWalk 2.0

3) Shower Aids

US Amazon Link:

Cast Cover
Bath Stool

Canada Amazon Link:

Cast Cover
Bath Stool

4) Vitamin D drops - 2000 IU / day

Please start this now - in preparation for surgery.



US Amazon Link:

Vitamin D drops

Canada Amazon Link:

Vitamin D drops

5) Aspirin 81 mg / day

If you do not have a contraindication for taking aspirin.  I would recommend you take an Aspirin 81 mg / day for each day that you are in the cast.


US Amazon Link:


Canada Amazon Link:


6) Foam Bed Wedge to elevate feet



US Amazon Link:

Foam Bed Wedge

Canada Amazon Link:

Foam Bed Wedge

7) Advanced healing waterproof band-aids


 
US Amazon Link:

Advanced Healing Band-aids

Canada Amazon Link:

Advanced Healing Band-Aids


8) Diet.  Make sure you are eating a good well balanced diet with adequate amounts of protein and fruits + vegetables.  No junk food.  No fast food.  No sugar. No smoking.

Friday, 1 April 2016

Recommended shoes if you have 1st MTP arthritis / 2nd MTP arthritis / Midfoot arthritis and don't want surgery

Essentially you are looking for a rigid shoe with a rocker bottom.  This will decrease motion across the 1st MTP joint + midfoot and decrease pain in the foot.

Clarks Wave:


US Amazon Link: Clarks Wave

Canada Amazon Link: Clarks Wave

Hoka One running shoe:


US Amazon Link: Hoka One

Canada Amazon Link: Hoka One

MBT shoes / sandals:


US Amazon Link: MBT shoes

Canada Amazon Link: MBT shoes

Platform Sandal - rigid shoe with rocker bottom:


US Amazon Link: Platform Sandal

Canada Amazon Link: Platform Sandal

Dansko Clogs:


US Amazon Link: Dansko Clog

Canada Amazon Link: Dansko Clog

Fit Flop:


US Amazon Link: Fit Flop

Canada Amazon Link: Fit Flop

Birkenstock Sandal / Shoe:


US Amazon Link: Birkenstock

Canada Amazon Link: Birkenstock

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.

Saturday, 6 July 2013

Lisfranc / Midfoot 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:


Non-union at 10 months required revision fusion.



Case 18:


Case 19:


Case 19.1:

Patient wanted hardware removal at 1 year post-op.



Case 20:


Case 21:


Case 22:


Case 23:


Case 24:


Case 25:


Case 26:


Case 27:


Case 28:


Case 29:


Case 30:


Case 31:


Case 32:


Case 33:

ORIF revision to fusion


Case 34: