Homolateral Lisfranc Fracture/Dislocation of 1st - 5th Metatarsals in a Collegiate Quarterback: A Case Study

Abstract

Category: Sports; Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low- energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals. We present a novel surgical technique for repair of homolateral Lisfranc fracture/dislocation of the 1st-5th metatarsals. Fusion of the 2nd and 3rd TMT joints provides stability of the middle column. Internal bracing of the 1st TMT joint gives stability while preserving greater physiologic motion in a high-level athlete. Methods: A dorsal approach is used for fusion of the 2nd and 3rd TMT joints with medial approach for internal bracing of the 1st TMT joint. 2nd and 3rd metatarsals were denuded of cartilage, and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites. Guidewire for the cannulated Internal Brace system is inserted into the base of the 1st metatarsal. Fluoroscopic imaging confirmed positioning and the 3.4mm drill is passed over the wire, followed by the cannulated tap. A 4.75mm Swivelock anchor with Fibertape suture is inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm Swivelock is then loaded with the Fiberwire from the 1st metatarsal. Tensioning is performed, and the 3.5 mm Swivelock is inserted into the medial cuneiform. Results: The athlete was cleared to return to full competition 9 months following surgery with physical exam demonstrating stability in both dorsiflexion and abduction. Weight bearing x-rays showed no evidence of hardware failure and no instability in the 1st TMT joint. CT scan demonstrated solid fusion of 2nd and 3rd TMT joints and maintained anatomic reduction of the 1st TMT joint. At 1-year post-op, patient was having pain over the 4th TMT joint. He had a second surgery to remove an exostosis at the 4th TMT joint as well as remove the screw from the 3rd metatarsal to the middle cuneiform. His pain had resolved at most recent follow up. He returned to game action in the final game of his senior season. Conclusion: The literature demonstrates return to sport is possible for athletes with Lisfranc injuries though the data focuses on either purely ligamentous injuries or Myerson type B and C fractures. This case study demonstrates a novel surgical approach to homolateral fracture/dislocation. While return to sport in this athlete took longer than lower-energy injuries, it is possible for athletes with homolateral displacement to return to full competition.