Wk 5, Case 4 - Review

Patient History
18-year-old female with a chronic wound following Lisfranc ligament repair with graft, now complaining of increased drainage and pain.

Findings
Skeletal/osseous:
Evidence for previous C1 M2 Lisfranc ligament repair. Graft severely attenuated. Fluid intensity material within the medial cuneiform surgical tract, along the region of the severely attenuated graft and proximal 2nd metatarsal surgical tract. Cortical/osseous erosion surrounding the surgical graft/surgical site (involving the proximal 2nd metatarsal, base of 1st metatarsal and medial cuneiform). Extensive osteoedema throughout the proximal to mid 1st metatarsal, medial cuneiform, proximal to mid 2nd metatarsal, intermediate cuneiform. Exuberant periosteal reaction involving the proximal shaft of the 2nd metatarsal. No subperiosteal abscess.

Articulations:
Unremarkable.

Lisfranc joint:
Status post previous C1 M2 Lisfranc ligament repair as described above. Markedly attenuated infected graft, with diffuse periligamentous edema/fluid signal.

Tendons:
The partially imaged flexor digitorum longus and flexor hallucis longus tendons are unremarkable in appearance. No evidence for flexor tenosynovitis. Extensor tendon of the 2nd digit is mildly displaced by the adjacent phlegmonous soft tissue mass, without associated tenosynovitis. The remaining extensor tendons are intact and unremarkable in appearance. No tenosynovial sheath effusion or abscess.

Ligaments:
Noncontributory.

Plantar plates:
Intact.

Soft tissues:
2.2 x 0.9 cm dorsal subcutaneous midfoot abscess/phlegmon with a communicating sinus tract connecting with the infected Lisfranc ligament repair site. The midfoot abscess/phlegmon is immediately superficial to the extensor tendons (extensor hallucis longus and 2nd extensor digitorum tendon). A sinus tract is seen extending from the medial cuneiform into the deep subcutaneous tissues of the medial midfoot.
No bulky Morton neuroma. Reactive 1st intermetatarsal space bursal thickening with a small effusion. Nominal reactive 2nd intermetatarsal space bursal thickening.
Other:
Edema of the muscles surrounding the proximal 2nd metatarsal.

Impressions
1. Status post previous C1 M2 Lisfranc ligament repair with infected graft/surgical site and surrounding PERIGRAFT osteomyelitis (involving the proximal 2nd metatarsal, lateral base of the 1st metatarsal, and medial cuneiform). No evidence for graft incorporation (graft failure).
2. Inflammatory phlegmon/abscess formation dorsal subcutaneous tissue with a sinus tract/tail to the Lisfranc joint. Recommend fluid aspiration/analysis.
3. Sinus tract/involucrum medial cuneiform.