3/6/2014 • • Foot and Ankle Fusions‐You Can't Always Replace Us Disclosure Statement 1st through 3rd TMTJ (Lisfranc) Fusion Nothing to Disclose Jeffrey R. Baker, DPM, FACFAS Weil Foot & Ankle Institute Des Plaines, IL Jeffrey R. Baker, DPM, FACFAS Weil Foot & Ankle Institute Des Plaines, IL Indications Primary Arthrodesis Primary Arthrodesis Salvage/revision procedure Ly TV, Coetzee JC. Treatment of primarily ligamentous lisfranc joint injuries: primary arthrodesis compared with open reduction internal fixation. JBJS 2006 88:514‐520 – Methods • In‐situ [Without deformity] • Forefoot realignment – Post‐traumatic arthritis – Atraumatic tarsometatarsal osteoarthritis • Pes planus • Hallux Valgus • Rocker bottom foot – Charcot Salvage/Revision Arthrodesis Methods • In situ – No attempt at realignment • Slight deformity • Forefoot realignment – Sagittal plane – Transverse plane • • • • 20 patients ORIF 21 patients Primary arthrodesis of medial 2 or 3 TMTJ articulations Mean 3.4 year follow‐up Conclusion: A primary stable arthrodesis of the medial 2 or 3 rays appears to have better short and medium‐term results than open reduction and internal fixation of ligamentous Lisfranc joint injuries Tarsometatarsal Articualtion • Medial column – 1st metatarsal cuneiform joint • Middle column – 2nd and 3rd metatarsal cuneiform joints • Lateral column – 4th and 5th metatarsocuboid joints 1 3/6/2014 Clinical Work‐up • • • Symptoms – Localized pain – Impingement syndrome Stress manipulation – Determine the column of pain • Simultaneous pronation and inversion of the midfoot Joint injections Imaging Work‐Up • Weightbearing radiographs – Compare to contralateral foot • Talus‐fist metatarsal angle • Distance of medial cuneiform to the floor • MRI • CT – 3D CT Incisions • Medial aspect of foot overlying 1st metatarsal/medial cuneiform joint • Incision centered between 2nd and 3rd metatarsals ***Be aware of dorsalis pedis artery and the superficial portion of the deep peroneal nerve*** Trephine Arthrodesis Ryan JD, Timpano ED, Brosky TA. Average depth of tarsometatarsal joint for trephine arthrodesis. J Foot Ankl Surg 2012 51:168‐174 – – – – 51 cadaveric specimens 32.3 mm 1st TMTJ 26.9 mm 2nd TMTJ 23.6 mm 3rd TMTJ Trephine Arthrodesis • Historic? – Trephine joint resection & dowel grafts [in‐situ] Withey CJ, Murphy AL, Horner R. Tarsometatarsal joint arthrodesis with trephine bone resection and dowel calcaneal bone graft. J Foot Ankl Surg 2014 58:243‐247 – 2nd TMTJ exposed – 12.5‐mm diameter trephine – 20 mm depth with plantar cortex maintained – 4 hole locking plate – NWB 6 weeks post‐op Conclusion: Recommended for the treatment of tarsometatarsal osteoarthritis with minimal or no repositioning required Standard Arthrodesis • Joint resection & internal fixation – Deformity correction through joint resection – Fixation for fusion of 1st‐3rd TMTJ » Lag screws » Cannulated screws » Plates » Compression staples – Bone graft 2 3/6/2014 Joint Resection • Power Realignment • Complete reduction of malalignment – Saw – Rasp – Transverse plane – Sagittal plane • Hand – Chisels – Osteotomes – Rongeur Corner Fusion Technique Results Komenda GA, Myerson MS, Biddinger KR. Results of athrodesis of the tarsometatarsal joints after traumatic injury. JBJS 1996 78:1665‐1676. – Retrospective review of 32 patients – Mean 35 months after injury Conclusion: Patients had marked improvement with respect to both pain and function after arthrodesis Post‐operative Care • Non‐weightbearing – Overall consensus • 8‐12 weeks 3 3/6/2014 Summary • Multiple indications – Most common post traumatic • Work‐up deformity – Determine column of injury • Forefoot realignment – Sagittal and transverse planes • Extended non‐weightbearing post‐ procedure Thank You 4
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