Christina Kabbash - Select Physical Therapy

Christina Kabbash, M.D., Ph.D., M.P.H.
Orthopaedic Surgery,
Foot and Ankle Specialist
Greater Hartford Orthopaedic Group
August 2, 2016
June 15, 2016
255 Lisfranc injuries
documented in the
NFL Injury Surveillance System
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Rare in the 1990’s
From 2000-2005, the NFL saw an average of
14.5 per season
Increased to 18.9 Lisfranc injuries per season
2006-2014
Injuries are tracked through the NFL Injury
Surveillance System
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In existence since 1980
Since 2012 collecting longitudinal outcome data:
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Head, Neck, and Spine
Foot and Ankle
Cardiovascular
When and injury occurs the team’s Athletic
Trainer opens a form in ISS and enters a
medical diagnosis for the injury; details about
the activity in which the player and team were
participating
During recovery the trainer updates the form
with any treatments or surgeries the player
receives
When the player returns to play the trainer will
update and close out the form
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2006: Michael Strahan, Giants defensive end
2011: Matt Schaubb, Houston Texans quarterback
2012: Santonio Holmes, Jets Star receiver
2012: Cedric Benson, Green Bay Packers running back
2012: Ryan Kalil, Carolina Panthers center
2012: Maurice Jones-Drew, Jacksonville Jaguars running back
2013: Le’Veon Bell, Pittsburgh Steelers running back
2013: Jake Locker, Tennessee Titans quarterback
2013: Barrett Jones, St. Louis Rams offensive lineman
2014: Zach Miller, Chicago Bears tight end
2014: Phillip Thomas, Washington Redskins safety
2015: Ben Roethlisberger, Pittsburgh Steelers quarterback
2000 : Errict Rhett, Cleveland Browns running back
2012: Robert Johnson, Titans safety
Midfoot fracture/dislocation through the arch
ú Jacques Lisfranc de St. Martin
was a Franch surgeon and
gynecologist in Napoleon’s
army.
ú In 1815 he first described the
injury in an equestrian soldier
who had fallen from a horse but
his foot remained trapped in the
stirrup.
ú The foot in this case likely
developed a
compartment syndrome
as it became gangrenous
requiring amputation
through the
tarsometatarasal
(Lisfranc) joints
ú A “Lisfranc injury” today
refers to a fracture and/or
dislocation through the
TMT joints.
1.
2.
3.
Twisting of the foot
Crushing of the foot
Axial load on a plantar flexed
foot
2013 Interview with Dr. James Anderson, Co-chairman of
NFLs Foot and Ankle Committee and Carolina Panthers
Team Physician
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Etiology is multi-factorial: Bigger (heavier), faster
stronger players and lighter weight, more flexible
shoes
“When the cleat engages with the turf, if it doesn’t
release at a certain level of torque, then injury can
occur”
2013 Interview with Dr. James Anderson, Co-chairman of
NFLs Foot and Ankle Committee and Carolina Panthers
Team Physician
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“We are finding it particularly in running backs and
defensive ends as they come around the offensive
tackle and also in defense backs changing directions”
“Bizarre” since it is very difficult to reproduce in the
lab
1.
Twisting of the forefoot
ú Equestrian forefoot trapped in a stirrup
ú Rotational force on a plantar flexed foot (cleats planted and
foot rotates)
ú More and more the injures are occurring without contact –
occurs when a player cuts or twists leaving his fore foot
planted
2. Crush
Displacement of the metatarsals
in the direction of the force
3.
“Classic” Axial
loading with
the foot fixed
in equinus
Causes the
metatarsals either
to displace as a
group or to split
apart
In the 1990s Myerson reported a 4% incidence
per year of tarsometatarsal injuries in collegiate
football players by this mechanism
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May occur when the foot is plantar flexed
and another player lands on the heel
Or, a lineman is forced back on a foot that is
already plantar flexed
Lisfranc’s
Ligament
Runs from
plantar aspect
medial
cuneiform to
the base of the
second
metatarsal
The first metatarsal is
attached only to the
medial cuneiform;
no intermetatarsal
ligament
attachment
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Requires a high degree of clinical suspicion
1. 20% misdiagnosed
2. 40% no treatment in the 1st week
Be wary of the diagnosis of “midfoot
sprain”
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Midfoot pain with
weight bearing
Swelling across the
dorsum of the foot
Deformity variable
due to possible
spontaneous
reduction
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Athletes complain
of inability to push
off the ground
with the foot and
generate power
Champ Bailey
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Lisfranc Injury
2013 (no surgery)
Returned after
injury for part of
the 2013 Broncos
Super Bowl run,
then foot pushed
him to retire the
following year
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PLANTAR
ecchymosis may
appear late
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Gentle stressing
pronation/
abduction and will
reveal instability
AP view:
Medial shaft of second
MT aligns with medial
aspect of middle
cuneiform
Fleck sign indicating
avulsion of Lisfranc
ligament
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TMT disruption
Lateral displacement
2MT on middle
cuneiform
1-2 MT gap
AP
3rd MT aligns with
lateral cuneiform
4th MT aligns with
cuboid
Cuboid crush
OBL
Lateral view:
Dorsal (>plantar)
displacement of the
metatarsals relative
to the tarsal bones
Best seen on
weightbearing view
Nonweight bearing Xrays have
a 50% sensitivity for the
diagnosis of Lisfranc
Weight bearing Xrays have a
85% sensitivity for the
diagnosis of Lisfranc
Stress views, CT scans,
MRI for definitive Dx
Terry Thomas/Leon Spinks Sign
ADduction/supination
ABduction/pronation
Terry Thomas/Leon Spinks Sign
ABduction/pronation
No instability on weight bearing views but
positive midfoot tenderness
TX: midfoot sprain or
nondisplaced fxs
treated with immobilization and NWB
SO, if a Lisfranc injury is confirmed by an MRI
or a CT, but stress views are negative
NO ROLE FOR SURGERY
Treated nonweight bearing immobilized for 6
weeks if fractures; NWB until nontender if
no fractures
Consensus: NO role for nonoperative treatment if
fracture-dislocation present or ligamentous
instability noted on stress views
casting provides poor restraint to displacement
and does not address interposed ligements and soft
tissues
Deformity with midfoot arch collapse
Post traumatic degenerative arthritis
Shoe fitting problems
Pain and disability
Dorsal capsule and associated ligaments
disrupted
Lisfranc ligament intact
No instability with stress views
Does well non-op
Not much strain on the dorsal ligaments
during gait
Usually no healing problems
Postoperative scar tissue encasing EDLs
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Perfect anatomical reduction is most important
concept
Screw technique, WB status, ROH are all
secondary
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Short leg “AO” splint for 2 weeks
CAM with home ankle ROM
Maintain NWB for 6 weeks
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Begin PT at 6 weeks
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K wires pulled in the office at 6 weeks
Hardware (screws/plates) removal at four
months for ORIF
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Denver Broncos
Brandon Marshall,
Lisfranc surgery early
2015, waited to have
screws removed until
after SuperBowl 50;
broke his hardware
Has retained broken
screws
How do patients with these injuries do?
Which technique is best at improving patient
outcome?
What is the expected tie to return to play and level of
play after these injuries?
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11 pts examined retrospectively after ORIF
with gait analysis to determine functional
outcome
Avg FU 41.2 months (14-53)
AOFAS midfoot score ave 71.0
After anatomic reduction of Lisfranc joint ,
gait analysis returns to normal
Subjective outcomes less than satisfactory
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All injuries considered ligamentous and acute injuries
41pts - ave followup = 42 months
Randomized - ORIF v Immediate fusion
ORIF group (20 patients)
16/20 had hardware removed because of pain at average
of 6.75 months
15pts after ROH had loss of correction, increasing
deformity, and/ or development of midfoot arthrosis
7pts converted to arthrodesis
65% of pts had returned to previous level of activity at
2year follow-up
AOFAS midfoot score at final follow-up = 57.1
11/20 satisfied with surgery at 2yrs
Arthrodesis group (21 patients)
4/21 needed 2nd procedure to remove hardware and in
1 patient bone grafting
92% returned to pre-injury activity level 2yrs after
surgery
100% satisfied with surgery at 2yrs
AOFAS midfoot score 86.9 (p>0.0001)
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Removal of hardware performed at average of 6.75
months may have contributed to complications in ORIF
group
Study recommended arthrodesis for ligamentous
Lisfranc injury based on improved short/ medium term
follow-up data
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40 patients, 24 months
Combined purely ligamentous (25%) and
fractures
Identical approach - envelope opened after
exposure obtained!
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No difference in satisfaction rates at 24 months
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Reop rate of 78.6% in the ORIF group
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One conversion to arthrodesis; one broken screw
11/16 ROH at 4 months
Reop rate of 16.7% in the arthrodesis group
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3 ROH; one painful hardware, 2 per request
One delayed union with broken screw
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A literature review of proimary arthrodesis
versus ORIF was performed
Six studies, 193 patients
ORIF:
FUSION:
AOFAS score 72.5
AOFAS score 88
DiGiovanni C, et al. 2012. Arthrodesis versus ORIF for Lisfranc Fractures
Orthopedics 35(6)
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A literature review and meta-analysis was
performed. 3 studies utilized. No new trials
since 2012.
No difference in patient satisfaction
Higher Reop rate ORIF
Furey A, et al. 2016. Does Open Reduction Internal Fixation versus Primary
Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? Clin Orthop Relat Res. June 474(6), 1445-­52.
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Purely ligamentous Lisfranc injuries with disruption
of the Lisfranc joint and associated instability
(stress/WB >2mm) do better with surgery.
Mixed as to whether primary arthrodesis vs ORIF
outcomes are better in fracture patients
ORIF will allow more midfoot ROM in the elite
athlete (nonessential joints?) but will require a
second surgery for ROH and possibly arthrodesis if
instability recurrs after ROH, or, post-traumatic
degenerative arthritis develops
Sennett BJ, et al. Outcomes of Lisfranc Injuries in the
National Football League. Am J Sports Med. May 10
2016
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28 NFL players (11 offensive, 17 defensive) who
sustained a Lisfranc injury between 2000-2010.
22 players required surgery, 6 managed
nonoperatively
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Time to return to competition
Total games played after season of injury
yearly total yards and touchdowns for
offensive players
Yearly total tackles, sacks, and interceptions
for defensive players
Compared 3 seasons before and 3 seasons
after injury
Control group: uninjured players in the 2005
season
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2/28 (7.1%) never returned to play)
26/28 (92.9%) returned to play 11.1 months
from the time of injury and missed a median
of 8.5 regular season games
Analysis of pre- and post- injury
performance did not show any statistical
significance changes after return to play
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84.6% f the NFL players sustained season
ending injuries; only 3 players returned in
the same season
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Mc Cullough, KA. Surgical Intervention for
Athletes with Lisfranc Injuries Likely Allows
for Return to Sport. AOFAS Long Beach, CA
meeting, July 29, 2015.
25 collegiate and NFL players with ORIF
Lisfranc from 2000-2013.
81% returned to play at an average of 10
months postop
3 of the NFL players achieved ProBowl Status
post injury
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Anderson J “Guru”
40 of Anderson’s surgical patients: 34 NFL, 6
collegiate
NFL: 79% RTP 10 months postop
Collegiate: 100% RTP 8 months postop
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Incidence increasing
Etiololgy changing and multifactorial
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From axial loading type injuries to twisting
Increased weight, speed, flimsier shoes, longer
cleats, type of turf
Most players prefer lighter weight shoes and spikes
that grip the turf better
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Rehab is lengthy either with or without
surgery: 8 months to a year
No well defined rehab protocols
Fusion for ligamentous instability; ORIF for
fractures in elite athletes
Greater liklihood of second surgery (ROH)
with ORIF
When all else fails…..
THANK YOU
Christina Kabbash MD
Greater Hartford Orthopaedic Group
Sports
Spine
Joints
Hand
Foot and Ankle