Resection of the foot (by Lisfranc, Sharp or Chopard) is performed after restoration of blood supply to the lower limb or after stabilization of the destructive process in the foot due to diabetes mellitus. It is necessary for necrosis of all toes or the forefoot. Healing after resection is quite long, but as a result of success, the supporting function of the leg is preserved in full. After removing part of the foot, it is necessary to wear special shoes to prevent the development of arthrosis of the ankle joint due to changes in load.
Postoperative care
- Increased postoperative pain control is necessary.
- A patient with a diabetic foot must be taught how to care for the stump. When the swelling of the foot subsides and the pain disappears, you need to start doing physical therapy. It is very important to maintain physical activity.
- After Sharpe surgery, patients usually do not need a prosthesis. For comfortable movement you will need special inserts in your shoes.
- After Lisfranc resection, special high-top orthopedic shoes are required, which are attached to the ankle joint.
- After Chopard resection, prostheses are required that are fixed on the upper third of the leg.
- If phantom pain or depression occurs, you may need to take special medications or work with a psychologist.
Lisfranc joint
Injuries to the Lisfranc joint, represented by tarsometatarsal dislocations and fracture dislocations, are a fairly rare type of injury (about 0.2% of skeletal injuries), more common among men aged 20-30 years. The leading part of the injury is a rupture of the capsular-ligamentous complex between the inner cuneiform bone and the base of the second metatarsal. Injuries can range from a slight subluxation of the second tarsometatarsal joint to complete dislocation of the entire forefoot.
The most common causes of Lisfranc joint injuries are motor vehicle accidents, falls from heights, and sports injuries. The most common mechanism is axial loading through a plantarflexed foot and indirect rotational forces.
Another possible mechanism could be plantar hyperflexion or direct trauma (such as a car pedal) on the plantar side.
In this case, the traumatic force is distributed in the direction of flexion/adduction/axial compression, which leads to a displacement of the bases of the metatarsal bones to the dorsal and outer sides. If the traumatic force is great enough, it leads to fractures of the metatarsal and cuneiform bones.
There are such anatomical structures as the Lisfranc ligament, the Lisfranc joint and the Lisfranc articular complex. The Lisfranc joint complex consists of the tarsometatarsal joints, intermetatarsal joints, and intertarsal joints.
The most important point in understanding Lisfranc joint injuries is understanding the critical role of the Lisfranc ligament in stabilizing not only the second tarsometatarsal joint but also supporting the entire plantar arch. The Lisfranc ligament consists of three bundles and connects the medial cuneiform bone to the base of the second metatarsal. The Lisfranc ligament prevents excessive pronation and abduction of the foot.
The plantar tarsometatarsal ligaments, dorsal tarsometatarsal ligaments, and intertarsal ligaments also participate in the formation of the Lisfranc articular complex.
Due to the large number of ligaments and structural features of the joints, the Lisfranc joint complex is extremely stable with a small range of motion.
There are many clinical and radiological classifications of Lisfranc joint injuries, but none of them help in choosing treatment tactics and have little effect on the prognosis. For this reason, they will not be covered in this article.
Diagnosis of Lisfranc joint injuries is a complex task that requires a high level of skill and alertness from the orthopedic surgeon. Up to 25% of cases are missed during the patient’s initial visit.
Symptoms of Lisfranc joint injury include forefoot and midfoot pain that worsens with axial loading. Upon examination, a bruise is detected, often along the plantar surface, in the projection of the Lisfranc joint.
If there is significant displacement, gross deformation may be noticeable. The swelling spreads diffusely throughout the entire foot. Pain on palpation in the projection of the Lisfranc ligament.
For a full clinical diagnosis of fracture dislocation in the Lisfranc joint, one cannot do without assessing the degree of instability. Adequate anesthesia is required to perform these tests. To perform the test, grasp the 2nd-5th metatarsals with the fingers of one hand, and palpate the Lisfranc joint area from the back with the fingers of the other. When the metatarsal bones (second metatarsal bone) are displaced to the rear, dorsal instability is determined accordingly; if displacement inward or outward is possible, this is a sign of total instability and is an indication for surgical treatment.
For instrumental diagnostics, radiographs with/without stress are used in comparison with the healthy side; if they are of little information, it is recommended to perform stress radiographs, similar to the instability test given above.
During X-rays, all images are taken in comparison with a healthy foot. There are several basic radiographic signs of Lisfranc joint injury. 1. Lack of parallelism between the medial edge of the base of the 2nd metatarsal and the medial edge of the medial cuneiform bone 2. Widening between the bases of the 1st and 2nd metatarsals 3. Presence of a bone fragment in the area of the base of the 2nd-1st metatarsal bone 4. Dorsal subluxation on the lateral projection 5. Rupture lines of the tarsometatarsal joint.
In cases that are difficult from a diagnostic point of view, it is advisable to use CT and MRI.
The first to propose a classification of Lisfranc joint injuries were Quenu & Kuss back in 1909. They divided dislocations and fracture-dislocations in the Lisfranc joint into 3 main groups depending on the direction of displacement of the forefoot; group 1 included homolateral dislocations, in which the 2-3-4-5 metatarsal bones are displaced outward; group 2 included medial dislocations, in which the 1st-2nd metatarsal bones are displaced inwardly, and the 3rd group included divergent dislocations, in which the 1st ray is displaced inwardly and 2-3-4-5 outwardly.
The Quenu & Kuss classification of Lisfranc joint injuries was creatively revised and modified in accordance with the accumulated knowledge of Hardcastle & Myerson in 1999. Taking into account the requirements of the International Association of Osteosynthesis, fracture-dislocations in the Lisfranc joint were divided into 3 groups A, B, C depending on severity. Group A included medial and lateral subluxations, group B included medial and lateral dislocations, respectively, and group C included the most severe divergent injuries.
The above classifications refer to fracture-dislocations and dislocations in the Lisfranc joint, severe injuries that are more common in high-energy trauma, accompanied by a significant risk of complications. But in the second half, especially at the end of the 20th century, due to a significant increase in the number of people involved in sports, the frequency of low-energy injuries to the Lisfranc joint also increased. In this connection, Nunley & Vertullo in 2002 proposed a classification of isolated Lisfranc ligament injuries. Most often they occur during sports and other low-energy injuries, and affect only the middle column of the foot - 2-3 tarsometatarsal joints. Diagnosis of these injuries is extremely difficult, since radiographic signs are revealed only when performing stress radiographs. Nevertheless, this is an important orthopedic task, since grade 2-3 injuries, if left untreated, often lead to subsequent chronic pain in the foot and a significant limitation in the level of physical activity.
Conservative treatment is used in cases of isolated ligamentous damage (no fractures according to CT), with isolated dorsal instability. With multiple concomitant pathologies, low mobility, and severe neurotrophic disorders of the lower extremities, conservative treatment is also possible.
In other cases, surgical treatment is recommended. If you suspect a Lisfranc injury, you should always pay close attention to the condition of the soft tissues of the foot, since in some cases the formation of compartment syndrome occurs. If compartment syndrome is suspected, intracase pressure should be measured, and if it exceeds 30 mm H2O, a fasciotomy should be performed. This will avoid massive damage to soft tissue.
Emergency surgery is indicated only in cases of compartment syndrome, open injuries, and unrepairable dislocation. In other cases, it is advisable to perform reposition, temporary immobilization in a cast or external fixation device, and then carry out surgical treatment after the edema subsides.
If the displacement is more than 2 mm, instability during functional tests, open removal of the dislocation with rigid fixation with screws or plates is recommended. One or two longitudinal approaches are used in the 1st and 2nd intermetatarsal spaces. After exposure of the first tarsometatarsal joint, the first stage eliminates intersphenoidal instability, and the second stage eliminates tarsometatarsal instability. In the postoperative period, the development of an active range of movements immediately begins. The load on the foot begins gradually, in order to fully restore it by 6-8 weeks. Kirschner wires are removed after 6-8 weeks, compression screws after 3-6 months. Return to full physical activity no earlier than 9-12 months after surgery.
Open reduction of dislocation, transarticular fixation of 1-2-3 tarsometatarsal joints with screws.
Even in isolated ligamentous injuries with significant instability, arthrodesis of 1-2-3 tarsometatarsal joints is recommended. This type of treatment is characterized by fewer complications (such as post-traumatic arthrosis and migration of metal fixators) than open reduction with internal fixation. After surgery, it is recommended to wear a circular plaster immobilization for 6 weeks, walking without weight. Gradual increase in axial load from 6 to 12 weeks.
For progressive collapse of the arches of the foot, chronic instability, and progressive external displacement of the forefoot, arthrodesis of the entire Lisfranc joint complex is recommended. There are many options for performing this intervention, using pins, screws, staples and plates, depending on the equipment of the operating room and the preferences of the surgeon. After the operation, 6 weeks of plaster immobilization will be required; full load can be given no earlier than 10 weeks.
Nonunion during arthrodesis in the Lisfranc joint is extremely rare, but may require revision surgery using osteoplastic materials.
In some cases, it is advisable to use a mixture of surgical techniques. If we consider the entire Lisfranc joint divided into internal, central and external sections, then its internal (1) and lateral (4-5) sections are mobile, although with a small amplitude, and the central (2-3) is practically immobile. For this reason, in surgical practice, incomplete arthrodesis is often used, that is, arthrodesis of 2-3 tarsometatarsal joints is performed and 1,4,5 are temporarily fixed with knitting needles.
This allows you to maintain normal biomechanics of the foot and prevent the early development of arthrosis in adjacent joints, which is typical for complete arthrodesis.
Separately, it is worth considering the topic of Lisfranc ligament rupture with isolated instability of the 2nd tarsometatarsal joint. The incidence of this injury has increased significantly over the past 50 years due to the popularization of sports. The incidence of delayed diagnosis is also extremely high. With this pathology, the patient is bothered by pain along the dorsal surface of the 1-2-3 tarsometatarsal joints during physical activity. Often, upon examination, it is possible to detect deformation in this area. If examination is delayed several weeks or months after injury, instability will no longer be clinically detectable, but stress radiographs will show a diastasis between the medial cuneiform bone and the base of the 2nd metatarsal.
In cases of this injury, surgical treatment is indicated, open removal of subluxation of the base of the 2nd metatarsal bone with screw fixation. Subluxation is removed from an approach in the 1st intermetatarsal space; scar tissue and remnants of the ligament can interfere with the joint, and then they will need to be removed. After reduction, preliminary fixation with a pin and X-ray control are performed.
Then a screw is installed connecting the base of the 2nd metatarsal bone and the medial sphenoid bone.
After the operation, there is a 6-12 week period of immobilization in a rigid orthosis without axial load on the leg. Then the load is gradually increased to full over 4-6 weeks.
This method of surgical treatment is effective during the first 6-8 months after injury. If more time has passed since the injury, it is advisable to perform arthrodesis.
The screw is removed 6-12 months after surgery. In the case of the formation of painful post-traumatic arthritis of the 2nd tarsometatarsal joint, arthrodesis is also indicated.
Below I will give an example of treatment of a patient with chronic dislocation of the Lisfranc joint, which took place within the walls of our department.
Patients with fracture-dislocations in the Lisfranc joint often find themselves in a situation where no doctor wants to take on them. This happened with patient Zh., 64 years old, who was injured back in 2001, but they refused to operate on him. The pain and deformity progressed, and over the past 10 years the patient could no longer walk more than 800 meters. Constantly wearing orthotics did not provide relief from symptoms.
After an examination in the orthopedics department No. 2 of City Clinical Hospital No. 13, a decision was made to perform an operation - open removal of the dislocation, arthrodesis of 1-2-3 metatarsocuneiform joints, 1 intersphenoid joint using screws and a plate, transarticular fixation with knitting needles of 4-5 metatarsocuneiform joints .
The first stage is the removal of osteochondral exostoses and scar tissue from the area of the entire Lisfranc joint. After this, the distal part of the foot acquires sufficient mobility to restore normal anatomy. The remains of the articular cartilage are completely removed from the 1-2-3 metatarsal-wedge joints, 1 intercuneiform joint using a chisel, an oscillating saw, a Luer cutter, and a sharp Volkmann spoon. Bone pins are used for reduction.
The apex, key, locking wedge - in general, the main part of the Lisfranc joint is the 2nd metatarsocuneiform joint. For this reason, we prefer to start committing with it. For arthrodesis, we use screws with FT Arthrex threads directed in different directions with a diameter of 4 mm. They allow you to create powerful interfragmentary compression, and due to the deep thread, they are very securely fixed in the bone.
After restoration of 2 rays, we perform arthrodesis of the intersphenoid joint and 1 metatarsocuneiform joint. Considering that the main load falls on 1 beam, we additionally stabilize it using a plate.
The 3rd metatarsal-wedge joint is also fixed with a screw. It is advisable to keep the 4-5 metatarsal-wedge joints mobile, as this is important for normal gait biomechanics. Therefore, we do not remove the remnants of cartilage tissue from them. After resection of exostoses and scar tissue, they are repositioned (since they are in a state of displacement towards the rear and outwards) and fixed with 1.5-2 mm Kirschner wires. The pins will be removed after 8-10 weeks.
The patient remains in the hospital for the first 2 days after surgery. This is necessary to relieve pain and control the postoperative wound. On the 3rd day the patient is discharged home in a plaster cast and on crutches. You should not step on your foot until 6 weeks after surgery. Postoperative sutures are removed after 2 weeks; the splint bandage can be replaced with a circular regular or plastic plaster or orthosis.
After 6 weeks, X-rays are taken; if the X-ray picture is good, the patient is allowed dosed exercise. This means that he continues to walk with crutches, but can now place his foot on the floor. Floor scales are used to control the load; you should start with 20 kg, gradually adding 2-3 kg per day until the full load is reached by 10-12 weeks. At 8-10 weeks, wires from 4-5 tarsometatarsal joints can be removed.
As a result, after 3 months we get a stable, painless, weight-bearing limb. After 6 months, you can begin sports activities.
Causes
Types of Injuries
Most often, Lisfranc joint injuries occur in young people who lead an active lifestyle, play sports or work in heavy work.
Fracture-dislocations can be associated with a heavy object falling on the leg, being run over by a car, or, for example, an unsuccessful fall from a sufficiently high height.
Pathology can also occur when there is strong pressure on the foot from the plantar side, for example, with a car pedal, while the bones move upward and a dislocation occurs. But most often the injury is associated precisely with the impact of great force, which is why it is accompanied by a fracture of the metatarsal and tarsal bones.
There is no ligament between the 1st and 2nd metatarsal bones, so if you fall on a round protrusion, the bones may move to the side and thus displace the joint. Fractures are most often associated with the impact of great force on the foot with twisting and compression.
Treatment
Lisfranc joint injuries can be treated using two methods: conservative and surgical. Conservative therapy is used for mild dislocations without bone fractures, while the doctor holds the ankle with one hand and pulls the fingers with the other, thus realigning the bones. To remove the displacement to the side, the doctor creates forces by pulling the necessary part of the foot in the opposite direction.
The procedure is carried out under local anesthesia, and the procedure ends when a characteristic click sounds and the bones fall into place, and the deformity of the foot is also removed. If the reduction does not produce results, the procedure can be repeated again.
Open reduction of dislocation
If conservative treatment does not produce results, or the injury is severe, combined with a bone fracture, surgical treatment methods are used. As a rule, reposition and therapeutic immobilization are first performed, and after the swelling has subsided, surgery is scheduled. For open fractures, urgent surgical treatment may be prescribed.
During surgery, open reduction of displaced bones is performed, and they are also fixed with metal bolts and knitting needles, which are removed after six months or a year. After the operation, the foot is immobilized with a rigid orthosis for 3-4 months, and after its removal, gradual development of the foot is recommended over a month or two.
Anatomy and structure
The Chopart and Lisfranc joint is located in the center of the foot, which consists of the tarsus, metatarsus and toes. The tarsus is located at the toes and consists of a group of bones that includes:
- wedge-shaped;
- cuboid;
- scaphoid;
- heel;
- ram
The metatarsus is located closer to the base and includes 5 tube-shaped bones. The Lisfranc joint connects the metatarsus and tarsus together, running across the entire foot. This joint has wedge-shaped and cuboid-metatarsal joints, which connect all the small blocks of joints and bones of the foot to each other. The Lisfranc ligament has 3 bundles that connect the metatarsal bone and the medial bone.
The joints inside the foot hardly move; they are flattened as much as possible and serve as a support and support the entire body in an upright position. With this structure, it is important for the bones and joints of the foot to maintain their stable position as much as possible to ensure the desired type of mobility of the lower extremities.
The Chopart joint in the foot also transversely connects the calcaneocuboid and talonavicular joints. This joint has a bifurcated ligament, which begins on the heel bone and is attached to the bones of the metatarsus on both sides. The Chopart joint ensures the integrity of the foot and preserves it during movement. If the integrity of the Chopart joint is compromised, the patient completely stops mobility in the foot.
First aid
Fractures and dislocations of the foot require timely treatment, like any other fractures and dislocations. Therefore, if the foot is injured as a result of a collision with a car, or the fall of a heavy object, or under other circumstances, the first step is to fix it.
Immobilization of the injured limb
The victim is not recommended to stand on his sore leg on his own, to set the bones in place; he must call an ambulance, or take the patient to the hospital on his own.
Before placing the victim in a vehicle, it is imperative to immobilize the limb to prevent further displacement of the bones and deterioration of the condition.
To fix the leg, a splint is placed on it. If the fracture is open, you cannot remove anything from the wound and set the fractures yourself. Typically, the wound is covered with a loose sterile dressing or a clean handkerchief to protect it from dirt and infection. It is very important to give the victim pain relief so that during transportation the pain does not intensify and traumatic shock does not occur.
Functions and properties
The Chopard-Lisfranc joint has a complex structure that allows for the fixation of many small joints and bones inside the human foot. Most of the bones and joints in the foot are soft and flat to provide increased support to the lower extremities. Their active movement can lead to deformation of bones and feet, dislocation and fracture.
The main functions of the Chopard and Lisfranc joints are:
- stabilization of the position of small joints in the foot;
- fixation of the joints of the metatarsus, heel and tarsus;
- maintaining the position and arch of the foot;
- attachment of the metatarsus and tarsus to the heel;
- ensuring the required angle of rotation of the foot;
- maintaining the integrity of the entire foot.
Complications
For the treatment of fractures and fracture-dislocations of the tarsometatarsal bones, traditional medicine recipes are not used. This kind of injury requires mandatory medical intervention, as it is necessary to set the bones in place so that the joint can recover normally. If a patient refuses hospital treatment and the foot recovers on its own, but the bones are in the wrong position, the patient has a 90% chance of remaining disabled and limping even after the bones have healed.
In addition, due to the displacement of the bones, the joint begins to fray and collapse, subsequently causing chronic pain. A deformed foot ceases to perform a normal shock-absorbing function, which leads to the destruction of the ankle, knee and hip joints.
With open injuries, the wound may become infected and suppurate; as a result, blood poisoning and other complications may occur. Open fractures require immediate hospitalization and surgical treatment.
If you consult a doctor in a timely manner, in most cases the disease can be cured without consequences for later life. Over time, the foot is completely restored and its function returns to normal. But it is worth remembering that the earlier treatment for fracture dislocation was started, the better the prognosis.
Diagnostics
Only a qualified traumatologist or surgeon can correctly diagnose fracture-dislocation of the tarsometatarsal bones. You need to understand that similar symptoms can occur with various injuries that require specific treatment.
During the examination, the doctor usually observes displacement of the bones, which indicates the presence of a dislocation. Also conducts a survey of the patient, who, as a rule, associates foot pain with a recent injury, for example, a fall, an unsuccessful landing while jumping from a height. Usually the patient remembers well how the injury occurred, because the Lisfranc joint is quite stable and is not so easy to injure.
Trauma on x-ray
To confirm the diagnosis and clarify the presence of a bone fracture, the patient must undergo an x-ray, and pictures of both feet are taken, both the sick and the healthy one. But even after examination, doctors do not detect a dislocated joint in more than 20% of cases, and the treatment prescribed is not entirely correct.
To determine whether there is a dislocation in the Lisfunk joint, the doctor must check the degree of its instability. In this case, the doctor holds the foot by the second and fifth metatarsal bones and palpates the Lisfunk joint; normally, no displacement is observed. This study is quite painful for injuries, so it is performed under local anesthesia.
In cases where other studies have not given a comprehensive result, the doctor may refer the patient to a CT or MRI, but this happens quite rarely and in severe cases, since tomography is a fairly expensive method, and it is quite possible to identify a foot injury with radiography.