All joints are assessed for inflammation, deformities, and contractures. The patient's ability to perform activities of daily living (ADLs) is evaluated. The patient is assessed for fatigue. Vital signs are monitored, and weight changes, pain (location, quality, severity, inciting and relieving factors), and morning stiffness (esp. duration) are documented. Use of moist heat is encouraged to relieve stiffness and pain. Prescribed anti-inflammatory and analgesic drugs are administered and evaluated; the patient is taught about the use of these medications. Patient response to all medications is evaluated, esp. after a change in drug regimen, and the patient and family are taught to recognize the purpose, schedule, and side effects of each. Over-the-counter drugs and herbal remedies may interact with prescribed drugs and should not be taken unless approved by physicians or pharmacists. Inflamed joints are occasionally splinted in extension to prevent contractures. Pressure areas are noted, and range of motion is maintained with gentle, passive exercise if the patient cannot comfortably perform active movement. Once inflammation has subsided, the patient is instructed in active range-of-motion exercise for specific joints. Warm baths or soaks are encouraged before or during exercise. Cleansing lotions or oils should be used for dry skin. The patient is encouraged to perform ADLs, if possible, allowing extra time as needed. Assistive and safety devices may be recommended for some patients. The patient should pace activities, alternate sitting and standing, and take short rest periods. Referral to an occupational or physical therapist helps keep joints in optimal condition as well as teaching the patient methods for simplifying activities and protecting joints. The importance of keeping PT/OT appointments and following home-care instructions should be stressed to both the patient and the family. A well-balanced diet that controls weight is recommended (obesity further stresses joints). Both patient and family should be referred to local and national support and information groups. Desired outcomes include cooperation with prescribed medication and exercise regimens, ability to perform ADLs, slowed progression of debilitating effects, pain control, and proper use of assistive devices. For more information and support, patient and family should contact the Arthritis Foundation (404-872-7100) ().
The patient's clinical presentation is consistent with a chronic Lisfranc injury with posttraumatic midfoot arthritis. Figure A shows an acute Lisfranc injury with diastasis between the medial cuneiform and 2nd metatarsal.
The Lisfranc joint complex consists of tarsometatarsal, intermetatarsal, and intertarsal articulations. The Lisfranc ligament goes from medial cuneiform to base of 2nd metatarsal on plantar surface and provides transverse foot stability.
The Level 5 review article by Thompson and Mormino state that shoe inserts/modifications and nonsteroidal anti-inflammatory medications are the mainstay of non-surgical treatment for posttraumatic arthritis after Lisfranc injury. If these modalities fail, arthrodesis of the affected joints is the treatment of choice.
Illustration A shows the anatomic postion of the stout, plantar portion Lisfranc ligament with the deep band spanning from the medial cuneiform to the 2nd metatarsal and the superficial band extending to the 3rd metatarsal