Lisfranc injury in the athlete: evidence supporting management from sprain to fracture dislocation

Management of Lisfranc Injuries: A Critical Analysis Review

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There is a spectrum of midtarsal injuries, ranging from mild midfoot sprains to complex Lisfranc fracture-dislocations.

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Use of appropriate imaging can reduce patient morbidity, by reducing the number of missed diagnoses and, conversely, avoiding overtreatment. Weight-bearing radiographs are of great value when investigating the so-called subtle Lisfranc injury.

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Regardless of the operative strategy, anatomical reduction and stable fixation is a prerequisite for a satisfactory outcome in the management of displaced injuries.

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Fixation device removal is less frequently reported after primary arthrodesis compared with open reduction and internal fixation based on 6 published meta-analyses. However, the indications for further surgery are often unclear, and the evidence of the included studies is of typically low quality. Further high-quality prospective randomized trials with robust cost-effectiveness analyses are required in this area.

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We have proposed an investigation and treatment algorithm based on the current literature and clinical experience of our trauma center.

Retrospective chart review: Weightbearing CT scans and the measurement of the Lisfranc ligamentous complex

BACKGROUND

Lisfranc Ligamentous Complex (LLC) injuries are commonly misdiagnosed due to their unreliable projection on plain films. Weightbearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish widely referenced baseline anatomic positions.

METHODS

A retrospective chart review was conducted of patients who had undergone weightbearing CT of the bilateral lower extremities with one-hundred and twelve being included (56 patients). Measurements of the Lisfranc joint were collected by two independent reviewers. Uninjured symmetric anatomy was used to describe a baseline for normal anatomic variation and to evaluate for sex-based or age-related differences. These measurements were then compared against the injured side.

RESULTS

In patients without Lisfranc injury, the 1st metatarsal base to 2nd metatarsal base distance (Base M1-M2) was 2.7 + /- 0.7 mm; 2nd metatarsal base to medial cuneiform (M2-C1) was 3.7 + /- 0.7 mm; intercuneiform distance was 1.2 + /- 0.3 mm; and sagittal descent 12.2 + /- 5.4 mm. Patients with injury to LLC had a larger M1-M2 base distance (Δ = 0.5903, p < 0.0001) and M2-C1 interval (Δ = 1.8008, p < 0.0001) compared to uninjured side. Males had significantly higher M2-C1 (p = 0.0031), intercuneiform distance (p = 0.0039), and sagittal descent (p = 0.0008) compared to female patients. No significant differences were found between left versus right side in any of the measurements. Intercuneiform distance (p = 0.0039) was found to significantly decrease as age increased, while sagittal descent significantly increased with increased age (p = 0.0066).

CONCLUSION

Weightbearing CT has high utility in identification of Lisfranc injuries particularly when comparing injured and uninjured sides, which may be its greatest utility in defining injuries. This is evident in the excellent diagnostic ability of the M2-C1 measurement. By defining baseline anatomic measurements for Lisfranc complex parameters in our patient population, we provide normal parameters for comparison when evaluating potential subtle injuries.

LEVEL OF EVIDENCE

III.

Primary fusion versus open reduction internal fixation for purely ligamentous lisfranc injuries: A Prospective comparative study and analysis of factors affecting the outcomes

BACKGROUND

The studies evaluating the outcomes of treatment of purely ligamentous unstable Lisfranc injuries are scarce. This study aimed at comparing outcomes of primary tarso-metatarsal joints fusion versus open reduction and internal fixation in treatment of such condition and determining the possible factors that may alter the outcomes.

METHODS

This study comprised 30 patients; 16 in fusion group and 14 in ORIF group. One column was operated on in 2 patients, two columns in 21, and three columns in 7. The mean follow-up period was 36 months.

RESULTS

There was no statistically significant difference between both groups regarding patients or injury characteristics. The mean AOFAS and FFI-Rs scores were 88.9 and 22.7 in the fusion group, compared to 61.7 and 34.5 in the ORIF group (P = .03,.04 respectively). At final follow-up all patients in the primary arthrodesis group were maintaining an anatomical reduction versus 71.5% in the ORIF group. Sixteen patients (53%) reported prominent hardware troubles that required removal. Five patients in ORIF group developed osteoarthritis, and four of them underwent secondary fusion. There was significantly higher incidence of posttraumatic osteoarthritis in patients with non-anatomical reduction and complete injuries. Better mean AOFAS and FFI-Rs scores occurred with non-smokers and with anatomical reduction.

CONCLUSION

Based on this limited case series, purely ligamentous Lisfranc injuries were found to have better outcomes when managed with a primary fusion as compared to ORIF. Achieving and maintaining anatomical reduction was the most important factor that is significantly attributed to improved outcomes. Possible arthritic changes and additional surgeries apart from implant removal could be avoided by primary fusion.

LEVEL OF EVIDENCE

level I- prospective comparative case study.

Arthrodesis in Acute and Chronic Lisfranc's Patients: A Retrospective Cohort Study

Injury to Lisfranc's joint complex affects the longitudinal and transverse arches of the foot and can significantly alter its biomechanics. Some of the previous studies have suggested primary arthrodesis to be superior to open reduction and internal fixation for treating primarily ligamentous Lisfranc injuries. Additionally, arthrodesis is often used for treating chronic Lisfranc injuries, including those which previously underwent open reduction and internal fixation and subsequently developed arthrosis. The purpose of this study was to retrospectively evaluate the outcomes of arthrodesis at the level of Lisfranc's articulation for both acute and chronic injuries. Patients who underwent midfoot arthrodesis surgical procedures between years 2001 and 2017 were retrospectively reviewed. About 187 patients with an average age of 55.9 ± 13.2 years old and a minimum follow-up of 1 year were included in the study. Median time to return to preoperative activities was 11 weeks. Overall successful joint fusion rate was 81.4%. However, concomitantly fused joints of the midfoot and hindfoot, in addition to the tarsometatarsal joints (TMTJ), were included in the overall fusion rate. Fusion rate at the first TMTJ was 90.2% (101 out of 112), second TMTJ was 94.4% (67 out of 71), and third TMTJ was 97.8% (45 out of 46). The present study demonstrates that patients who undergo arthrodesis for both acute and chronic Lisfranc injuries typically can return to activity in under approximately 3 months postoperatively (acute patients significantly faster) with a high union rate at the TMTJs. However, the overall union rate is significantly lower when concomitant proximal midfoot and rearfoot arthrodesis procedures are performed.

Computational analysis of the clinical presentation of a ligamentous Lisfranc injury

Lisfranc injuries in the midfoot disrupt key arches of the foot which, if left untreated, can progress to pain, dysfunction, and arthritis. A clinical challenge is that 30-40% of Lisfranc injuries are missed in initial evaluations. The objective of this study was to explore different conditions of limb loading that could influence the biomechanics of the Lisfranc joint in a validated computational model. A computational model was created using SolidWorks software to represent the bones and soft tissues of the lower leg and foot. The model was compared to a cadaveric study of healthy and injured Lisfranc joints. The model was then used to simulate weight-bearing radiographs and evaluate how muscle activity and foot position impacted the diastasis of the Lisfranc joint, a key indicator used to diagnose Lisfranc injuries. The computational model was within one standard deviation of the cadaveric study in all measurements for the healthy and injured foot. When simulating weight-bearing radiographs, the presence of muscle activity or inversion/eversion resulted in less joint separation for the model with ligamentous Lisfranc injuries. While previous research has noted that weight-bearing radiographs provide better conditions to assess Lisfranc injuries than nonweight-bearing, this study suggests that in weight-bearing radiographs both altering the position of the foot, possibly due to pain, and the active contraction of the extrinsic flexor muscles can obfuscate indications of a Lisfranc injury.

Clinical Study on Different Methods of Internal Fixation for Treatment of Lisfranc Joint Injury

The Lisfranc joints are mainly used to connect the forefoot and midfoot and maintain the stability of the arch of the foot. It is an important part of the arch of the foot. If the Lisfranc joints injury is not treated in time, it will cause poor walking, pain in the back of the foot, and even deformity or disability of the forefoot. The common treatment method is to select the Kirschner wires, screws, or steel plates for incisional repositioning internal fixation surgery. In our study, we used different materials to perform fixation surgery on Lisfranc joint injury patients. We measured the joint recovery, pain condition, complications, and biomechanical indexes of different groups of patients after the operation. The results of the study showed that compared with Kirschner wire and screw internal fixation, the use of shaped arch bridge-type microsteel plate internal fixation for the treatment of metatarsotarsal joint injury patients has better foot function recovery, fewer complications, and more reliable biomechanical strength.

The Lisfranc Injury: A Literature Review of Anatomy, Etiology, Evaluation, and Management

Despite being first described in the 1800s, the Lisfranc injury remains one of the most controversial topics in foot and ankle surgery. From the basic anatomy of the ligament complex to the optimal diagnostic and management methods, new research both sharpens and yet confounds our understanding of this unique injury. This article reviews the literature from established and classic papers to recent studies evaluating newer techniques. We discuss the unique bony and ligamentous anatomy, which confer strength to the Lisfranc complex, the typical mechanisms of injury, the most common classification systems, the clinical presentation, current imaging modalities, and conservative and surgical treatment options. We review studies comparing open reduction and internal fixation with primary arthrodesis of acute injuries, in addition to studies evaluating the various methods for obtaining fixation, including intra-articular screws, dorsal plates, and flexible fixation. It is clear from this review that despite the vast number of studies in the literature, much is still to be learned about the diagnosis and management of this challenging injury.Levels of Evidence: Level V: Expert opinion.

In-Season Management of Acute and Subacute Sports Foot Injuries

In athletes, foot injuries present with a variety of mechanisms, severity, and implications for return to play. Although potentially given less attention than knee and shoulder injuries by the team physician, foot injuries are common and thus require knowledgeable consideration. In this article, we review the anatomy, presentation, workup, and management of several of the most common athletic foot injuries, including turf toe, Lisfranc injuries, Jones fractures, and navicular stress fractures. The goal is to provide the team physician with the information necessary to evaluate and manage these injuries on the sideline and in the training room.

Sports-Related Lisfranc Injuries and Recognition of Lisfranc Variants: Surgical Strategies for Stabilization

Much has changed since Lisfranc described lesions at the tarsometatarsal (TMT) joint in 1815. What was considered an osseous high-energy condition nowadays is understood as myriad possible presentations, occurring in minor and inconspicuous traumas. Advancements in diagnostics of Lisfranc injury allow recognizing many variants of this trauma presentation, most of them with a focus on ligaments. This perception shifted trends in surgical planning, especially for implants and fixation techniques. These revolutions established a new and evolving universe around TMT lesions, different from what was known only a few years ago and still not enough to completely settle the disease scenario.

Study of the functional results of the percutaneous surgical treatment of subtle injuries of the tarso-metatarsian complex

INTRODUCTION AND OBJECTIVES

The concept subtle Lisfranc defines low energy lesions of the tarsometatarsal joint complex (TMC) that involve joint instability. Often unnoticed, with long-term sequelae. The objective is to evaluate the clinical-functional results of patients with MTC ligament damage grade II-III (Nunley and Vertullo classification) treated with percutaneous surgery.

MATERIAL AND METHODS

Retrospective study of 16 patients who underwent percutaneous surgery for MLC ligament damage. Demographic data, days of delay in diagnosis, surgical technique, joint reduction in load (adequate if C1-M2 space is less than 2 mm) and Manchester-Oxford scale (MOXFQ) score were collected. The sample consisted of nine males and seven females, mean age 43.6 years (17-71) and mean follow-up of 22 months (12-28).

RESULTS

Diagnosis was delayed for more than 24 hours in four patients (3-6 days). In 11 patients the treatment consisted of closed reduction and percutaneous synthesis with cannulated screws from M2 to C1 and from C1 to C2. In three patients it was supplemented with Kirschner wires in the lateral radii. Two patients were treated with only M2 to C1 screws. An anatomical reduction was not achieved in six patients, with a mean of 2.6 mm between C1-M2 (2.1-3 mm); the mean functional MOXFQ score of these patients was 41.1% (IC 95% 23.1-59.1%), worse results compared to the anatomical reduction: 17.2% (IC 95% 5.7-28.7); statistically significant difference (p < 0.01).

CONCLUSION

Subtle injuries from MTC are rare and can go unnoticed. Surgical treatment with percutaneous synthesis offers good clinical-functional results in the medium term. The anatomical reduction is a determining factor for the good functional result of our patients.

Rates of Displacement and Patient-Reported Outcomes Following Conservative Treatment of Minimally Displaced Lisfranc Injury

BACKGROUND

While surgery is indicated in Lisfranc fracture-dislocations, the natural history and optimal management of minimally displaced injures are unclear. The aim of this study was to define the rate of subsequent displacement and to determine the clinical outcome after conservative treatment of minimally displaced Lisfranc injuries.

METHODS

Over a 5-year period (2011-2016), 26 consecutive patients with minimally displaced Lisfranc injuries presenting to a single university teaching hospital were identified retrospectively using hospital electronic records. Patient demographics, injury mechanism, and radiological outcomes were recorded. Patient-reported outcome scores (PROMS) were collated at least 1 year postinjury and included the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ).

RESULTS

The rate of displacement was 54% (14/26). The median time to displacement was 18 days (range, 2-141 days). Forty-six percent (12/26) of the Lisfranc injuries remained minimally displaced after 12 weeks of conservative treatment. Initial weightbearing status was not associated with the risk of subsequent displacement (P = .9). At a mean follow-up of 54 months, PROMS were comparable between patients whose injury remained minimally displaced and those that required surgery for further displacement, despite the delay to surgery (AOFAS 78.0 vs 75.9, MOXFQ 24.8 vs 26.3, P > .1).

CONCLUSION

There was a high rate of displacement after initial conservative management of the minimally displaced Lisfranc injuries. Subsequent surgical management of displaced injuries resulted in outcomes comparable to those that remained minimally displaced.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

[Development and clinical application of ankle prosthesis]

OBJECTIVE

To review the development and clinical application of ankle prosthesis.

METHODS

The recent literature on ankle prosthesis design and clinical application was reviewed and analyzed.

RESULTS

Compared with the hip and knee prostheses, the ankle prosthesis develops slowly and has been developed to the third generation. The ankle joint has a special structure of multi-axis movement. The design of the first and second generations of prostheses is not conformed to the biomechanics of the ankle. The third generation of prosthesis is more conform to the characteristics of ankle biomechanics, with high postoperative survival rate and satisfactory clinical outcome.

CONCLUSION

At present, the survival rate of ankle prosthesis is low, and there is still much room for improvement in biomechanics, materials, and other aspects.

Return to sport following Lisfranc injuries: A systematic review and meta-analysis

BACKGROUND

Information regarding return rates (RR) and mean return times (RT) to sport following Lisfranc injuries remains limited.

METHODS

A systematic search of nine major databases was performed to identify all studies which recorded RR or RT to sport following lisfranc injuries.

RESULTS

Seventeen studies were included (n=366). For undisplaced (Stage 1) injuries managed nonoperatively (n=35), RR was 100% and RT was 4.0 (0-15) wks. For stable minimally-displaced (Stage 2) injuries managed nonoperatively (n=16), RR was 100% and RT was 9.1 (4-14) wks. For the operatively-managed injuries, Percutaneous Reduction Internal Fixation (PRIF) (n=42), showed significantly better RR and RT compared to both: Open Reduction Internal Fixation (ORIF) (n=139) (RR - 98% vs 78%, p<0.019; RT - 11.6 wks vs 19.6 wks, p<0.001); and Primary Partial Arthrodesis (PPA) (n=85) (RR - 98% vs 85%, p<0.047; RT - 11.6 wks vs 22.0 wks, p<0.002).

CONCLUSIONS

Stage 1 and stable Stage 2 Lisfranc injuries show good results with nonoperative management. PRIF offers the best RR and RT from the operative methods, though this may not be possible with high-energy injuries.

LEVEL OF EVIDENCE

IV. Systematic Review of Level I to Level IV Studies.

[Effectiveness of open reduction and internal fixation for acute and delayed occult Lisfranc injuries]

Objective

To evaluate the effectiveness of open reduction and internal fixation (ORIF) in treatment of acute and delayed occult Lisfranc injuries.

Methods

A retrospective review of 26 patients with occult Lisfranc injuries who were treated with ORIF between July 2010 and July 2015 was applied. Fourteen patients were treated within 6 weeks after injury (acute group) and 12 patients were treated after 6 weeks of injury (delayed group). There was no significant difference between the two groups in gender, age, affected sides, and preoperative visual analogue scale (VAS) score, American Orthopedic Foot and Ankle Society (AOFAS) score, and physical and mental scores of Study Short Form 12 Health Survey (SF-12) ( P<0.05). The joint reduction, internal fixator, and traumatic osteoarthritis were observed by X-ray films. The pain degree, midfoot function, and quality of life were evaluated with VAS score, AOFAS score, and physical and mental scores of SF-12.

Results

All incisions healed by first intention with no complications. All patients were followed up with the mean follow-up time of 15 months (range, 12-24 months) in acute group and 15 months (range, 12-23 months) in delayed group. At last follow-up, the VAS score, AOFAS score, and physical and mental scores of SF-12 were superior to those before operation in the two groups ( P<0.05). And there was no significant difference in all indicators between the two groups ( P>0.05). The satisfaction rates were 100% and 83.3% (10/12) in acute group and delayed group, respectively. The internal fixators were removed in 20 patients (11 cases in acute group and 9 cases in delayed group) at 9-24 months after operation (mean, 14.5 months). The results of X-ray films showed no traumatic osteoarthritis, midfoot collapse, internal fixation failure, or reduction loss during follow-up period.

Conclusion

ORIF is an ideal method for both acute and delayed occult Lisfranc injuries and can obtain the similar effectiveness.

Low-Energy Lisfranc Injuries in an Athletic Population: A Comprehensive Review of the Literature and the Role of Minimally Invasive Techniques in Their Management

Tarsometatarsal (TMT) joint complex injuries can be caused by either direct or indirect injuries. The Lisfranc joint represents approximately 0.2% of all fractures. Up to 20% of these injuries are misdiagnosed or missed on initial radiographic assessment; therefore, a high index of suspicion is needed to accurately diagnose TMT joint injuries and avoid the late sequelae of substantial midfoot arthrosis, pain, decreased function, and loss of quality of life. This review discusses the anatomy, diagnosis, and management of athletic Lisfranc injuries, including a description of the preferred minimally invasive surgical techniques used by the senior author of this article.

Reoperation Rate Differences Between Open Reduction Internal Fixation and Primary Arthrodesis of Lisfranc Injuries

BACKGROUND

Controversy persists as to whether Lisfranc injuries are best treated with open reduction internal fixation (ORIF) versus primary arthrodesis (PA). Reoperation rates certainly influence this debate, but prior studies are often confounded by inclusion of hardware removal as a complication rather than as a planned, staged procedure inherent to ORIF. The primary aim of this study was to evaluate whether reoperation rates, excluding planned hardware removal, differ between ORIF and PA. A secondary aim was to evaluate patient risk factors associated with reoperation after operative treatment of Lisfranc injuries.

METHODS

Between July 1991 and July 2016, adult patients who sustained closed, isolated Lisfranc injuries with or without fractures and who underwent ORIF or PA with a minimum follow-up of 12 months were analyzed. Reoperation rates for reasons other than planned hardware removal were examined, as were patient risk factors predictive of reoperation. Two hundred seventeen patients met enrollment criteria (mean follow-up, 62.5 ± 43.1 months; range, 12-184), of which 163 (75.1%) underwent ORIF and 54 (24.9%) underwent PA.

RESULTS

Overall and including planned procedures, patients treated with ORIF had a significantly higher rate of return to the operation room (75.5%) as compared to those in the PA group (31.5%, P < .001). When excluding planned hardware removal, however, there was no difference in reoperation rates between the 2 groups (29.5% in the ORIF group and 29.6% in the PA group, P = 1). Risk factors correlating with unplanned return to the operation room included deep infection ( P = .009-.001), delayed wound healing ( P = .008), and high-energy trauma ( P = .01).

CONCLUSION

When excluding planned removal of hardware, patients with Lisfranc injuries treated with ORIF did not demonstrate a higher rate of reoperation compared with those undergoing PA.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Tarsometatarsal Arthrodesis for Lisfranc Injuries

This article discusses tarsometatarsal arthrodesis for Lisfranc injuries. Although open reduction and internal fixation has traditionally been the treatment of choice for most Lisfranc fracture-dislocations, there is a trend toward primary fusion, especially for purely ligamentous injuries. Consideration should be made for primary fusion in select fracture-dislocation cases. Primary fusion offers a single-stage alternative with potentially more stable, predictable results overtime.

Management of Tarsometatarsal Joint Injuries

Joint disruptions to the tarsometatarsal (TMT) joint complex, also known as the Lisfranc joint, represent a broad spectrum of pathology from subtle athletic sprains to severe crush injuries. Although injuries to the TMT joint complex are uncommon, when missed, they may lead to pain and dysfunction secondary to posttraumatic arthritis and arch collapse. An understanding of the appropriate anatomy, mechanism, physical examination, and imaging techniques is necessary to diagnose and treat injuries of the TMT joints. Nonsurgical management is indicated in select patients who maintain reduction of the TMT joints under physiologic stress. Successful surgical management of these injuries is predicated on anatomic reduction and stable fixation. Open reduction and internal fixation remains the standard treatment, although primary arthrodesis has emerged as a viable option for certain types of TMT joint injuries.

Efficacy of open reduction and internal fixation with a miniplate and hollow screw in the treatment of Lisfranc injury

PURPOSE

To investigate efficacy of open reduction and internal fixation with the miniplate and hollow screw in the treatment of Lisfranc injury.

METHODS

Ten cases of Lisfranc injury treated by open reduction, miniplate and hollow screw in our hospital were retrospectively analyzed. There were 6 males and 4 females with age ranging from 25 to 45 years (mean 32 years). Among them, one case was classified as Type A, six Type B and three Type C. Injury mechanism included road traffic accidents (3 cases), fall from height (5 cases) and hit by heavy object (2 cases). All injuries were closed without cerebral trauma or other complicated injuries. The time interval between injury and operation was 6-10 days (average 6.6 days). Postoperatively, the foot function was assessed using Visual Analogue Scales (VAS) and American Orthopaedic Foot and Ankle Society (AOFAS) Scales. Healing time and complications were observed.

RESULTS

All patients were followed up for 18-24 months (average 20 months). Anatomic reduction was achieved in all patients on images. There was statistical significance between preoperative score (7.89 ± 0.34) and score at postoperative 8 weeks (0.67 ± 0.13). According to the AOFAS score, 5 cases were defined as excellent, 3 cases as good and 2 cases as fair. During follow-up, there was no wound infection or complications except for osteoarthritis in 2 cases. Healing time ranged from 3 to 6 months with an average of 3.6 months.

CONCLUSION

Anatomical reduction of Lisfranc injury can be achieved by open reduction and internal fixation with the miniplate and hollow screw. Normal structure of Lisfranc joint is regained to a great extent; injured ligaments were also repaired. Therefore, this method offers excellent curative effect and can avoid postoperative complications and improve the patients' quality of life.