Das Lisfranc-Gelenk bezeichnet das Tarsometatarsalgelenk. Das Lisfranc-Band ist ein starkes Band, welches das mediale Os cuneiforme mit der Basis des zweiten Os metatarsale verbindet. Die Lisfranc-Verletzung als Folge eines Niedrigenergietraumas (Verstauchung) tritt vorwiegend bei Feldsportarten auf, wenn einem Spieler während des Laufens auf den Fuß getreten wird. Zu Lisfranc-Frakturen/Luxationen als Folge eines Hochenergietraumas kommt es häufig bei Stürzen aus großer Höhe oder Verkehrsunfällen mit Frontalzusammenstoß.

Foot and Ankle

Procedure

Die posttraumatische Arthrose ist eine häufige Komplikation nach einer Verletzung des Lisfranc-Gelenks. Schlagen konservative Maßnahmen fehl, können Patient/-innen von einer selektiven Arthrodese der symptomatischen Gelenke profitieren. Arthrex stellt Operateur/-innen Low-Profile-Platten, Nitinol-Klammern, kopflose Kompressionsschrauben und biologische Augmentationsoptionen bereit, womit eine erfolgreiche Fusion ermöglicht wird.

The new Lisfranc Plates were designed to provide fixation for acute Lisfranc injuries and fusions of the tarsal-metatarsal joints. The unique design allows for compression along the Lisfranc ligament and allows the surgeon to visualize the healing process during recovery. These plates come in three different sizes with both left and right plates to fit any patient and are contoured to fit the Lisfranc anatomy at only 1.4 mm thick.

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A step-by-step demonstration of how a product would (or could) be used in a surgical technique.

Eine schrittweise Demonstration, wie ein Produkt in einer Operationsanleitung verwendet werden würde (oder könnte).

Operationsanleitungen

Demonstração passo a passo de como um produto seria utilizado em uma técnica cirúrgica.

Guias de técnicas cirúrgicas

Demostración paso a paso de cómo se utilizaría un producto en una técnica quirúrgica.

Guías de técnicas quirúrgicas

Surgical Technique Guides

Lisfranc Reduction for Injuries and Fusions using Lisfranc Plates

The plantar lapidus plate has many proven clinical advantages compared to a dorsal or dorsal/medial-based lapidus plate. Most importantly, an earlier return to weightbearing can be achieved, allowing patients to get back to normal activities much sooner.

video

Plantar Lapidus Plate Product Demonstration

The Arthrex plantar lapidis plate is an innovative solution for a lapidary procedure to correct first tarsometatarsal joint instability. Unlike other plates, the Arthrex plantar lapidis plate acts as a tension band on the plantar first tarsometatarsal joint, providing superior biomechanical fixation and strength. This is in contrast to traditional lapidis fixation techniques, which are placed dorsally or medially, and therefore do not resist the plantar mechanical forces in the same manner during weight bearing, during ambulation or walking as the foot contacts the weight bearing surface, ground reactive forces are applied to the first metatarsal, causing the foot to elevate and a plantar distraction force to be exerted at the tarsometatarsal joint. Due to the nature of the hardware, these forces are not protected, and as a result, failure of the fixation can occur, causing displacement and disrupted healing. The plantar lapidis plate is positioned on the tension side of the joint, providing maximum biomechanical strength. The plantar fixation prevents disruption and the potential for plantar gapping. With this construct, as the patient ambulates, ground reactive forces attempt to elevate the first metatarsal. However, the plantar lapidis plate resists the same distraction force exerted at the tarsometatarsal joint by acting as a tension band. This converts the distraction forces into valuable compression forces across the joint, further facilitating fusion and healing. With multiple plate offerings for left and right feet at short and standard lengths, the Arthrex plantar lapidis plate provides surgeons a great tool to help treat their patients better.

Dorsal Midfoot Fusion Plates

Lisfranc-Arthrodese

Child (D)

Die FT-Kompressionsschrauben aus Titan (Vollgewinde) sind in den Größen Micro (2.5 mm), Mini (3.5 mm), Standard (4 mm), Large (5 mm) und XL (7 mm) erhältlich. Das variabel abgestufte Gewinde und das kopflose Design tragen zur Verringerung des Risikos von Komplikationen durch prominente Schraubenköpfe bei, bieten Kompression und ermöglichen ein vereinfachtes Einbringen. Die Operateure können so nun ohne Implantatprominenz eine stabile Fixierung erreichen. Die FT-Kompressionsschraubenfamilie eignet sich mit ihren 5 Durchmessern und 91 Schraubenlängen für zahlreiche orthopädische Anwendungen im gesamten Körper.

5.0 mm Large and 7.0 mm x-Large Compression FT Screw System

Imaging and Resection

Minimally Invasive Surgery - Medializing Calcaneal Osteotomy Surgical Technique

Hand and Wrist

The Arthrex MIS platform allows surgeons to perform minimally invasive bunion surgery with equivalent results to traditional open procedures.1
Reference
1. Brogan K, Lindisfarne E, Akehurst H, Farook U, Shrier W, Palmer S. Minimally invasive and open distal chevron osteotomy for mild to moderate hallux valgus. Foot Ankle Int. 2016;37(11):1197-1204. doi:10.1177/1071100716656440

MIS Surgery Bunion Correction

Arthrex presents a minimally invasive bunion correction to correct mild to moderate bunion deformities. First, palpate or outline the dorsal and planter aspects of the first metatarsal and halex. It can also be helpful to mark out the bisection of the shaft on the metatarsal neck, using fluoroscopy as a guide. A five millimeters incision is made with the beaver blade at the midline of the metatarsal, and just proximal to the sesamoid complex. Blunt dissection is carried down to bone, and a curved periosteal elevator is used to dissect subperiosteal in the intended path of the burr. It is important to make sure the extensor tendon and soft tissue structures remain dorsal to the periosteal elevator. The two millimeter by 19mm burr is introduced proximally to the sesamoid complex midline at the metatarsal in advance to puncture both the medial and lateral cortex of the metatarsal. It is important to note the initial trajectory of the miss Burr to ensure the surgeon accounts for maintaining, lengthening or shortening the metatarsal based on Based on the angle of the burr. At this point, the dorsal and plantar aspects of the transverse cut are completed with the burr. By rotating the handle first plantar, then dorsal to complete the osteotomy. Upon completion of the osteotomy, the helix is rotated under fluoroscopy via supination and pronation to confirm the osteotomy is complete. Next, a two millimeter double tipped guidewire is placed antegrade through the incision towards the distal aspect of the toe in an extra periosteal fashion. The pinch should exit the skin midline and medial to the distal phalanx. A curved hemostat is placed through the incision and into the proximal metatarsal shaft to assist in lateral translation of the capital fragment. When the surgeon is satisfied with the translation and rotation of the sesamoid complex while holding simultaneous abduction of the helix, the guidewire is advanced midline through the medullary canal until it is abutting the proximal aspect of the metatarsal near the TMT joint. This will help maintain the lateral and rotational translation of the capital fragment. At this stage, the hemostat can be removed if desired. The capital fragment can be supinated manually via the helix to correct the sesamoid position further. Finally, in preparation for final fixation, two parallel 1.1 guidewires are placed midline from the base of the metatarsal shaft. It is critical to ensure the most proximal wire is inserted in a bicortical fashion prior to entering the capital fragment. This enhances the overall construct stability. The second guidewire is placed in a similar trajectory, one centimeter distal to the initial wire. This wire is critical to provide anti-rotation strength to the overall construct. During early weight bearing, skin, incisions are made and the cannulated depth gauge is inserted over both guide wires to determine the necessary screw lengths. A general rule of thumb is to remove four millimeters from the measured length of the screw. Next, the cannulated drill is drill is inserted over the proximal guidewire, ensuring that the drill is advanced along the entire length of the wire and into the capital fragment, leaving the wire in place. The appropriate length 4.0 compression screw is inserted over the wire. Finally, the process of drilling and implanting the second screw is repeated to complete fixation of the metatarsal osteotomy to ensure appropriate alignment of the helix, and osteotomy is also recommended for this procedure. Initially, a five millimeter incision is made midline on the helix in line with the intended starting point of the osteotomy. After blunt dissection is carried down to the bone, the periosteal elevator is utilized to create a dorsal implanter working space for the burr. The two millimeter by 13 millimeter burr is introduced midline, aiming for distal medial to proximal lateral in order to create a medial wedge osteotomy. Rotate the burr handle plantar and then dorsal to create a transverse cut in the bone while maintaining the lateral cortex to act as a hinge. Gentle manipulation is applied to reduce and compress the osteotomy. Next, place a 0.86mm guidewire across the osteotomy from distal lateral to proximal medial. An incision is made with the beaver blade and the wire is measured. Drill over the wire with the cannulated drill and finally insert the 2.5 compression foot screw to complete the construct. Finally, if necessary, the redundant bone shelf can be removed utilizing a 2.9mm wedge burr. The incisions are closed. A compressive bandage can be applied and the construct is complete.

5.0 mm and 7.0 mm Compression FT Screws

FT-Kompressionsschrauben mit Vollgewinde

Product

Schwache, bloße Bandverletzungen des Lisfranc-Gelenks sind schwierig zu erkennen und erfordern aufgrund ihres subtilen Erscheinungsbildes einen hohen Verdachtsindex, insbesondere bei Sportlern. Für eine korrekte Diagnose können Röntgenaufnahmen unter Belastung in Kombination mit CT und MRT notwendig sein. Jede Diastase, die größer als 2&nbsp;mm ist, wird als positiv für eine Lisfranc-Verletzung angesehen.
Herkömmliche Fixierungsmethoden mit Schrauben und/oder Platten sorgen für ein stabiles Konstrukt bei Lisfranc-Verletzungen, können aber das Gelenk überlasten. Infolgedessen besteht das Risiko, dass die Patient/-innen das Aktivitätsniveau vor der Verletzung nicht wieder erreichen. Darüber hinaus erfordert die rigide Fixierung häufig einen zweiten chirurgischen Eingriff zur Materialentfernung, bevor das Gelenk wieder voll belastet werden kann, und birgt das zusätzliche Risiko für einen Repositionsverlust.
Flexible Produkte zur Fixierung wie das knotenlose 2.7&nbsp;mm Mini TightRope-Implantat und das Lisfranc-Fixierungssystem für die InternalBrace-Rekonstruktion beheben die Unzulänglichkeiten einer rigiden Fixierung und bieten ein starkes und reproduzierbares Konstrukt zur Stabilisierung des Lisfranc-Gelenks.
Literatur 
1. Arthrex, Inc., Archivdaten (APT-05278). Naples, FL; 2021. 
2. Arthrex, Inc., Archivdaten (APT-05279). Naples, FL; 2021.

Lisfranc Fixation System for InternalBrace™ Repair

Kirk A. McCullough, MD (Leawood, KS), demonstrates the repair of a Lisfranc injury with intercuneiform instability using the InternalBrace™ ligament augmentation system. InternalBrace repair addresses the intraosseous component of the Lisfranc ligament using a collagen-coated FiberTape® suture with a metallic button on the second metatarsal and a 4.75 mm SwiveLock® anchor in the medial cuneiform for knotless fixation.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

Lisfranc Injury Repair With the InternalBrace™ Ligament Augmentation Procedure

Yeah. So doctor McCullough from Kansas City, what we're going over today is the lisfranc InternalBrace stabilization. And so what we have is we've already performed the dissection. So you want to be able to identify the lateral base of the second metatarsal. So this is that proximal lateral base of the second metatarsal right in here. And so this is where we're going to start with our button. So now moving on to placement of our guidewire protecting the neurovascular bundle. But then clearly identifying where the second metatarsal base laterally is coming in. You then utilize a K-wires. And so certainly in the situation where there's an injury that's present, the utilization of a reduction clamp, which is going to parallel the direction at which you're going to place this guidewire, is something that you'd want to have placed. And so similar to what you're seeing there, that's the the trajectory which we're trying to achieve with this choir, trying to hug the proximal lateral aspect of that second metatarsal base. We're center center on the lisfranc articulation and extra articular in regards to the second and the first TMT joints. Now, with coming through medially with our guidewire, make a small incision here to allow us to then over drill our guidewire. So then this will allow us to expose the proximal medial aspect of the medial cuneiform. So this drill is uniquely set up to allow you to just drill in 15mm to avoid any violation of the lisfranc articulation. And so you take that guide down to bone. And then drilling over the top of your guidewire, you flush that down. And so at this point what we're going to do is we're going to advance our guidewire through to we're only just a small portion of it is remaining dorsally. And so now we will load the collagen coated FiberTape into the small nitinol eyelet, and then only advancing about an inch of that. And so this is something that having already drilled this, you this, you can simply just advance this through by hand. And so now you can see where that button is sitting. Right along that dorsolateral cortex. You can see the track of our FiberTape as it's going through. Next what we'll do is we'll turn medially to be able to secure the FiberTape in place with the swivel lock and making sure you're down to bone. You'll then advance that swivel lock right over the top of the K-wires. You can now see in that same area where we had the diastasis previously. This is now where our lisfranc has now been reduced and secured. And so with this technique, what you're going to do is subperiosteal making sure that you're deep to the extensor hallucis longus. You're going to go over the dorsal aspect of the medial cuneiform to then identify where your FiberTape is exiting the bone medially, then using a hemostat to do that. You'll then feed the tails of the FiberTape to yourself and then bring those over dorsally, just like we're doing right now. Good. And we'll go ahead and drill. And so then you load the 3.5 swivel lock onto your FiberTape. And similar to what we discussed with our last fixation, you would have a clamp in place holding this reduced. And so then approximating what the length is you'll then mark at the laser line on your FiberTape. And then advance your swivel lock into place. So now you have a knotless construct that not only stabilizes the lisfranc articulation right in here, but you now also have the ability for any proximal variant instability through the intercuneiform joint to stabilize that from your more plantar medial exit from the medial cuneiform, now dorsally into the intermediate cuneiform.

Eric Giza, MD, (Sacramento, CA) demonstrates the use of the Arthrex® Lisfranc fracture plate. The Lisfranc plate was designed to allow compression along the Lisfranc ligament, while not violating the joint surface using this titanium, low profile, dorsal locking plate.

Lisfranc ORIF Using Dorsal Lisfranc Fracture Plate

Today we're going to look at using the Arthrex Lisfranc fracture dislocation plate. It's particularly helpful when you have multiple tarsometatarsal instability. Also, for cases where you have comminution and you're going to go straight to a midfoot fusion. The concept behind this plate is that you're you're placing it on the middle and medial cuneiform, the first metatarsal as well as the the second metatarsal. So you can accurately either reduce or fuze the first and second TMT joints. If you make your incision over this area, you're going to be able to stay lateral to the neurovascular bundle and elevate it up. That also gives you the option of then making a medial incision if you need to have access over here, which sometimes we do. That way you're going to have the best exposure. Some people will make an incision sort of directly over the neurovascular bundle, but I prefer not to do that. And so now you have this exposure here and you're just being careful not to pull on it too much. But now you have first second TMT there. And then first TMT is going to be right over here. Okay. Because second is recessed in. Here's Liz Frank's articulation again making sure that we don't dissect too much any further down here because you worry about the neurovascular bundle there. I'm going to make a lisfranc injury right here. And you can see that. So you see the instability there. And we're going to be able to have this plate fit in here okay. And it fits just like that. And it's pre contoured which is quite nice. Because there's a bit of a bend so that it kind of comes over and fits right onto the base of the second. Then you take your, your plate and it's going to fit on here quite nicely. And then I'll put a tack. And you can use that to hold it in place. Good. That holds the plate in place. So we're in the middle medial cuneiform. Right now depth is usually going to be somewhere in the 20s. And this is indeed a 22 okay. And then you can use lockers. And again, if you have first TMT instability which you often do in these these sort of multi cases, you'll also sometimes want to clamp the first TMT joint as well. 22. Sometimes the threat of attack can help just really to keep everything reduced and where you wanted it. Again when you're putting in locking screws, you want to make sure the construct is down on the bone because once they go in, you're sharing plate bone interface, and once the locking screws go in, it's a plate to screw interface. So you want to make sure that that you have the surface area down on the bone. So now we'll take that out. If you're trying to you're doing a fusion particularly in the setting of a trauma. This is going to give you that aluminum compression that you need. Eat. And you'll see a little bit of a squeeze here as it comes down. And the fluid kind of. There you go. Nice. That's fantastic. Good bite. And so now you see where you had your lisfranc articulation, which is right here. And your first EMT is right here. And your second TMT is right in there when you stress this. And you saw how when we stressed it before, you have really, really good stability. Again, in the setting of a trauma, this is very important. And then we just take these out and normally I will let the tourniquet down. Sometimes there will be some small branches coming across the DP that you want to cauterize. But otherwise again this this is a really good approach between the extensor digitorum longus tendons and that extensor hallucis brevis muscle which is right here.

Thomas G. Harris, MD, (Pasadena, CA) presents the treatment options for Lisfranc joint complex injuries.

Lisfranc Fracture Dislocations: Approaches for Stability

0.2% of all fractures. I think that's an underestimation personally, can lead to significant disability. The problem is, is that both of those x rays are considered lisfranc injuries, and they have significantly different treatments and they're significantly different injuries. But they have the same name, I think of the Lisfranc joint as a complex, not just a particular joint. And there's a high index of suspicion. They're often missed stress views. How do we determine how do we diagnose these things? Weight bearing views are helpful, but can be deceiving. I've been fooled on them. Sometimes things will often auto reduce or they'll just weight bear on the side of their foot so you can be fooled. The stress views are superior. The stress views can be a bit of a practical difficulty because you sometimes have to do them in the Or. In this case, you'll see that longitudinal pattern, and sometimes you'll see that medial Cartiform actually impact all the way into the navicular. So this is more common than you think. And then here you know the stress view on the left. There you can actually see the first TMT joints opening up. So a lot of times we always think the first TMT joint is stable, but it often isn't. The treatment options here standard Orff with trans articular screws. There's a former arthrodesis. We can use a TightRope, an internal brace, absorbable implants, and then bridge plating. Here are some Arthrex solutions for lisfranc injuries, particularly ORFs there from a spanning plate to many tightropes cannulated screws compression type screws. But the real question in terms of lisfranc is kind of how do we fix the fusions? Should be the high energy ones. And how do you know you'll know delayed multi-column displacement, regardless of the energy. If it's a revision case, I think the fusion is the way to go. And articular comminution even a single joint you can fuze. I'll fix the stress positive low energy ones and the displaced low energy ones, even especially in the athletes and the ones I'll leave alone. Are those medically unfit for surgery or the really, truly stressed negative ones which are rare. The ArthroLive ViewSense benefits for a case like this is it's just one surgery. It's not three, it's not the AWF, it's not the hardware removal. And then the fusion is just one case. I think there's definitely a biologic milieu early on in these where they really fix and they really, you know, you fuze these and they really do heal pretty fast given that they've had the injury. And there's a lot of factors ongoing. And the choice of fixation here is screws, double compression plates. Lapidis. Plates o'f. Maybe in the past. Thought to be the gold standard. The open approach for me always. I'm not doing percutaneous approaches, but there's a lot of questions that are unanswered. Do we need to do hardware removal on these? Should we? We're using compression. What about the late displacement after hardware removal. This was the case about 4 or 5 years ago. 300 pound barista. She was protected non-weight bearing for about three months. And that three and a half months. Right. When I'm ready to take the screws out between 4 to 6 months, that screw breaks. And the problem with that screw breaking is it's really hard to get off, and you have to overeem it to get it out. Many TightRope I think is really good for low energy injuries. There's some question out there whether there's any sagittal plane stability with it, but that's been refuted by a study and there's a little micro motion as well. So that actually might be a little bit better. And in these cases no hardware removal is needed. You can do the mini TightRope with the driver which has a thread through it. They're kind of going from medial to lateral. Or you can go dorsal to medial. And if you've got the cases where you've got the intercuneiform instability as well, you can use TightRope for that. Also, the Lisfranc InternalBrace is a new idea. Kind of the path of the internal brace is right through that interosseous ligament. Kind of creating kind of a quasi new ligament there allows for some collagen in growth there. You're going to put the button over the lateral side of the second metatarsal and then tension medially. So you can really dial in your tension with this sort of thing there. And you get collagen coated FiberTape. So the one thing to remember though, you still got to watch out for that sagittal plane instability. And if it is there, then you have to play it across the area as well. This frank dorsal plating is an idea we came up with. Supports the entire complex, not just not just the Lisfranc joint, allows for a little bit of motion in through there, and it's going to protect the joints. There's there's left and right, small, medium or large. The technical pearls for this is you want to try to use a tenaculum. You want to try to avoid any damage in the intra-articular joint. When you're reducing these, be careful about that first metatarsal screw. If you're not careful, you can actually tag the plantar aspect of the first TMT joint because it kind of inclines a little bit early. You want to put the medial cuneiform screw in first, and then the second metatarsal screw, and you actually compress across that area. And then you can put the other screws in either non locking or locking. One question is there's a lot of second metatarsal comminution on some of these. And that second metatarsal screw is non locking. But you can flip the plate 180 80 degrees and then make that a locking screw. And we can look at this in the in the lab. I've inserted probably 60 to 70 over the last 4 to 5 years. No plate breakages. They've removed over 75%. Some patients just don't want them to be removed. Good results in most, but not in everyone. A case a 23 year old just stepped off a curb. That's the stress view. They're so low energy but really a lot of displacement. So in this one we kind of hedge our bets and debrided that lisfranc joint as I just mentioned, but left the first and second TMJ joints alone. There's some images there. This was a 55 year old who fell off about ten feet, just crushed that lateral column there. And the decision tree, it's acute high energy older patient. So for this one we actually fuzed and we did an X fix on the lateral column there we have some spanning and then trans articular screws there for the fusion. So a lot of different options for the lisfranc. You've got screws. We've got TightRope. We've got internal braces and plates. High energy injuries I'd still recommend Fuzing. And the low energy ones are definitely controversial. No cartilage damage with the spanning plates.

Lisfranc-Luxation

Lisfranc-Arthrodese

FT-Kompressionsschrauben mit Vollgewinde

Fixierung einer Lisfranc-Verletzung