Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint

Lisfranc Sports Injuries: What Do We Know So Far?

Lisfranc sports injuries include tarsometatarsal joint injuries, which may be accompanied by fractures. They most commonly occur due to a blow or axial force. The aim of this review is to assess the current standards for surgical intervention in Lisfranc injuries resulting from sports-related accidents. This evaluation will cover the timing of treatment, the recovery process, and the appropriate timing for a return to normal sporting activities. This research was done via an analytical review of current literature. Methods included a structured search strategy on PubMed, Science Direct, and Google Scholar. The collated literature was processed using formal inclusion or exclusion, data extraction, and validity assessment. Joint involvement and severity were taken into account while classifying Lisfranc injuries. The primary fixation and fusion techniques for Lisfranc injuries were compared, and the surgical management of these injuries was examined in all of the literature. Treatment recovery times were examined, and the results were talked about. A variety of injuries, from minor sprains to serious fractures and rips, make up Lisfranc injuries. Although open reduction internal fixation (ORIF) in combination with primary arthrodesis (PA) is now thought to be the optimum course of treatment, its acceptance has increased. Patients with Lisfranc injuries can usually expect excellent outcomes and the return of joint function to its pre-injury form if the injury is appropriately assessed and treated. Lisfranc injuries are manageable and have a good recovery time if not neglected. The outcomes of management and surgical options are also quite satisfactory.

Is the diagnostic validity of conventional radiography for Lisfranc injury acceptable?

BACKGROUND

Lisfranc injuries mainly involve the tarsometatarsal joint complex and are commonly misdiagnosed or missed in clinical settings. Most medical institutions prefer to use conventional radiography. However, existing studies on conventional radiographs in Lisfranc injury lack a large population-based sample, influencing the validity of the results. We aimed to determine the diagnostic validity and reliability of conventional radiography for Lisfranc injury and whether computed tomography can alter clinical decision-making.

METHODS

This retrospective study included 307 patients with, and 100 patients without, Lisfranc injury from January 2017 to December 2019. Diagnosis was confirmed using computed tomography. A senior and junior surgeon independently completed two assessments of the same set of anonymised conventional radiographs at least 3 months apart. The surgeons were then asked to suggest one of two treatment options (surgery or conservative treatment) for each case based on the radiographs and subsequently on the CT images.

RESULTS

All inter- and intra-observer reliabilities were moderate to very good (all κ coefficients > 0.4). The mean (range) true positive rate was 81.8% (73.9%-87.0%), true negative rate was 90.0% (85.0%-94.0%), false positive rate was 10.0% (6.0%-15.0%), false negative rate was 18.2% (13.0%-26.1%), positive predictive value was 96.1% (93.8%-97.8%), negative predictive value was 62.4% (51.5%-69.7%), classification accuracy was 83.8% (76.7%-88.2%), and balanced error rate was 14.1% (10.2%-20.5%). Three-column injuries were most likely to be recognized (mean rate, 92.1%), followed by intermediate-lateral-column injuries (mean rate, 81.5%). Medial-column injuries were relatively difficult to identify (mean rate, 60.7%). The diagnostic rate for non-displaced injuries (mean rate, 76.7%) was lower than that for displaced injuries (mean rate, 95.5%). The typical examples are given. A significant difference between the two surgeons was found in the recognition rate of non-displaced injuries (p = 0.005). The mean alteration rate was 21.9%; the senior surgeon tended to a lower rate (15.6%) than the junior one (28.3%) (p < 0.001).

CONCLUSIONS

The sensitivity, specificity, and classification accuracy of conventional radiographs for Lisfranc injury were 81.8%, 90.0%, and 83.8%, respectively. Three-column or displaced injuries were most likely to be recognized. The possibility of changing the initial treatment decision after subsequently evaluating computed tomography images was 21.9%. The diagnostic and clinical decision-making of surgeons with different experience levels demonstrated some degree of variability. Protected weight-bearing and a further CT scan should be considered if a Lisfranc injury is suspected and conventional radiography is negative.

Does temporary bridge plate fixation preserve joint motion after an unstable Lisfranc injury?

BACKGROUND

Recently, temporary bridge plate fixation has gained popularity in the treatment of unstable Lisfranc injuries. The technique aims to reduce the risk of posttraumatic osteoarthritis, and after plate removal, the goal is to regain joint mobility. Here we explore marker-based radiostereometric analysis (RSA) to measure motion in the 1st tarsometatarsal (TMT) joint and asses the radiological outcome in patients treated with this surgical technique.

METHOD

Ten patients with an unstable Lisfranc injury were included. All were treated with a dorsal bridge plate over the 1st TMT joint and primary arthrodesis of the 2nd and 3rd TMT joints. The plate was removed four months postoperatively. Non- and weight-bearing RSA images were obtained one and five years postinjury to assess joint mobility and signs of osteoarthritis.

RESULTS

Detectable 1st TMT joint motion was observed in 2/10 patients after one year, and 6/9 patients after five years. At the final follow-up, mean 1st TMT dorsiflexion was 2.0°. Radiologically, the incidence of posttraumatic osteoarthritis was present in 4/10 patients after one year, and 5/9 patients after five years. All patients had observed TMT joint stability throughout the follow-up period.

CONCLUSION

Preservation of joint motion can be achieved with a temporary bridge plate fixation over the 1st TMT joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prospective cohort study/Therapeutically level IV.

Surgical controversies and current concepts in Lisfranc injuries

INTRODUCTION

Lisfranc injuries, not as rare as previously reported, range from ligamentous to complex fracture-dislocations. Anatomical studies have identified a complex of discrete structures, and defined the anatomical characteristics of the Lisfranc joint.

SOURCES OF DATA

A narrative evidence-based review encompassed and analyzed published systematic reviews. Outcomes included clinical and surgical decision-making, including clinical-presentation, diagnosis, pathological-assessment, surgical-management techniques and indications, post-surgical care and comparative outcomes.

AREAS OF AGREEMENT

Better understanding of the Lisfranc complex anatomy aids surgical treatment and tactics. Prognosis is related to injury severity, estimated by the number of foot columns affected. Surgical outcome is determined by anatomical reduction for most fixation and fusion techniques. Appropriate treatment allows return to sport, improving outcome scores.

AREAS OF CONTROVERSY

Identification of Lisfranc injuries may be improved by imaging modalities such as weight-bearing computer tomography. Recent evidence supports dorsal plate fixation as a result of better quality of reduction. In complex injuries, the use of combined techniques such as trans-articular screw and plate fixation has been associated with poorer outcomes, and fusion may instead offer greater benefits.

GROWING POINTS

Open reduction is mandatory if closed reduction fails, highlighting the importance of understanding surgical anatomy. If anatomical reduction is achieved, acute arthrodesis is a safe alternative to open reduction internal fixation in selected patients, as demonstrated by comparable outcomes in subgroup analysis.

AREAS FOR DEVELOPING RESEARCH

The current controversies in surgical treatment remain around techniques and outcomes, as randomized controlled trials are infrequent.

A modified three-incision approach to treating three-column Lisfranc injuries

PURPOSE

The most popular surgical approach to manage Lisfranc fracture-dislocations is the double-incision approach, which frequently causes a variety of complications, such as skin necrosis, rotational malreduction of the first tarsometatarsal joint (TMTJ) and lateral column dorsoplantar malreduction of the TMTJ. We introduce a three-incision approach to treat Lisfranc fracture-dislocations with only minor postoperative complications and good foot function.

METHODS

We prospectively selected 30 previously healthy patients, ranging from 18 to 60 years of age, but only 23 patients completed the follow-up and thus were finally included, with an average age of 38.1 ± 12.9 years. All patients have sustained Lisfranc fracture-dislocations involving all three-column; 13.0% (3/23) were Myerson classification type A (medial), 47.8% (11/23) were type A (lateral), and 39.1% (9/23) were type C2. All patients were treated via a three-incision approach: a long incision made along the lateral border of the second ray was used as a working incision to visualize and reduce the first three TMTJs, as well as to apply internal fixation instrumentation; a 2 cm medial incision was made at the medial side of the first TMTJ as an inspecting incision, ensuring good reduction of the first TMTJ in medial and plantar view; another 1 cm inspecting incision was made at the dorsal side of the fourth/fifth TMTJ to prevent sagittal subluxation of the lateral column. Mean ± SD was used for quantitative data such as operation time, follow-up time and foot function scores. Postoperative complications were documented, and foot function was evaluated using the American orthopaedic foot & ankle society score, foot function index and Maryland foot score at follow-up. The foot function of the injured foot and contralateral foot of the same patient was at the end of follow-up, and independent sample t-test was used for statistical analysis.

RESULTS

The median operation time was 117.9 ± 14.6 min (range 93 - 142 min). All complications occurred within three months after the operation, and included delayed wound healing (17.4%), superficial infection (8.7%), complex regional pain syndrome (4.3%) and neuroma (4.3%). There was no case of postoperative skin necrosis or malreduction. At the end of follow-up of 14.1 ± 1.2 months (range 12-16 months), the median American orthopaedic foot & ankle society score of the operated foot was 89.7 ± 5.7, the median foot function index was 21.7 ± 9.9, and the median Maryland foot score was 88.7 ± 4.8. There were no significant differences between the operated and contralateral sides, in terms of foot function, at the end of followup (p > 0.05).

CONCLUSION

The three-incision approach can provide adequate visualization of all TMTJs to ensure anatomical reduction and offer sufficient working space to apply internal fixation instrumentation, which is effective in treating three-column Lisfranc fracture-dislocations with minor soft tissue complications and satisfactory functional recovery.

Biomechanical Comparison of Fiber Tape Device Versus Transarticular Screws for Ligamentous Lisfranc Injury in a Cadaveric Model

BACKGROUND

The preferred method of fixation and surgical treatment for ligamentous Lisfranc injuries is controversial. Transarticular screws, bridge plating, fusion, and flexible fixation have been described, yet none have demonstrated superiority. Furthermore, screw fixation and plating often require secondary surgery to remove implants, leading surgeons to seek alternative fixation methods.

PURPOSE

To compare transarticular screws and a fiber tape construct under a spectrum of biomechanical loads by evaluating the diastasis at 3 joints in the Lisfranc complex.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight matched pairs of fresh, previously frozen lower extremity cadaveric specimens were fixed with either 2 cannulated transarticular crossed screws or a fiber tape construct with a supplemental intercuneiform limb. The diastasis between bones was measured at 3 midfoot joints in the Lisfranc complex: the Lisfranc articulation, the second tarsometatarsal joint, and the intercuneiform joint. Measurements were obtained for the preinjured, injured, and fixation conditions under static loading at 50% donor body weight. Specimens then underwent cyclic loading performed at 1 Hz and 100 cycles, based on 100-N stepwise increases in ground-reaction force from 100 to 2000 N, to simulate postoperative loading from the partial weightbearing stage to high-energy activities. Failure of fixation was defined as diastasis ≥2 mm at the Lisfranc articulation (second metatarsal-medial cuneiform joint).

RESULTS

There were no significant differences in diastasis detected at the Lisfranc articulation or the intercuneiform joint throughout all loading cycles between groups. All specimens endured loading up to 50% body weight + 1400 N. Up to and including this stage, there were 2 failures in the cannulated transarticular crossed-screw group and none in the fiber tape group.

CONCLUSION

The fiber tape construct with a supplemental intercuneiform limb, which does not require later removal, may provide comparable biomechanical stability to cannulated transarticular crossed screws, even at higher loads.

CLINICAL RELEVANCE

Ligamentous Lisfranc injuries are common among athletes. Therefore, biomechanical evaluations are necessary to determine stable constructs that can limit the time to return to play. This study compares the biomechanical stability of 2 methods of fixation for ligamentous injury through a wide spectrum of loading, including those experienced by athletes.

Salvage of Failed Lisfranc/Midfoot Injuries

Salvage of Lisfranc, or tarsometatarsal injuries, may be necessary because of a variety of clinical scenarios. Although rare, these injuries represent a broad spectrum of injury to the midfoot ranging from low-energy ligamentous injuries to high-energy injuries with significant displacement and associated fractures. Poor outcomes and complications may occur including posttraumatic arthritis, instability, pain, infection, and loss of function. Strategies and technical considerations for salvage of these complex injuries are provided.

Outcome after nonoperative treatment of stable Lisfranc injuries. A prospective cohort study

BACKGROUND

The aim of this study was to evaluate the outcome after nondisplaced and stable Lisfranc injuries.

METHODS

26 patients with injuries to the Lisfranc joint complex detected on CT scans, but without displacement were tested to be stable using a fluoroscopic stress test. The patients were immobilized in a non-weightbearing short leg cast for 6 weeks. The final follow-up was 55 (IQR 53-60) months after injury.

RESULTS

All the Lisfranc injuries were confirmed to be stable on follow-up weightbearing radiographs at a minimum of 3 months after injury. Median American Foot and Ankle Society (AOFAS) midfoot score at 1-year follow-up was 89 (IQR 84-97) and at final follow-up 100 (IQR 90-100); The AOFAS score continued to improve after 1-year (P=.005). The median visual analog scale (VAS) for pain was 0 (IQR 0-0) at the final follow-up. One patient had radiological signs of osteoarthritis at 1-year follow-up.

CONCLUSION

Stable Lisfranc injuries treated nonoperatively had an excellent outcome in this study with a median follow-up of 55 months. The AOFAS score continued to improve after 1 year.

Biomechanical Comparison of Fibertape Device Repair Techniques of Ligamentous Lisfranc Injury in a Cadaveric Model

BACKGROUND

Lisfranc ligamentous injuries are complex, and their treatment, along with the preferred method of fixation, is controversial. Implementing a flexible synthetic augmentation device (fibertape) has been described as an alternative to traditional screw fixation. This biomechanical study evaluated two fibertape devices with interference screw fixation: InternalBrace, and InternalBrace with supplementary intercuneiform stabilization.

METHODS

The diastasis and relative angular displacement between bones were measured at three midfoot joints in the Lisfranc articulation. Measurements were obtained for the pre-injured, injured, and post-fixation stages under static loading. Specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at 100 N ground reaction force intervals from 500 to 1200 N to simulate postoperative loading, and then up to 1800 N to simulate high loads. Failure of fixation was defined as diastasis greater than 2 millimeters at the second-metatarsal - medial-cuneiform joint.

RESULTS

InternalBrace specimens demonstrated failures in 3 of 9 (33%) specimens at cyclic loads of 1000 N. Conversely, InternalBrace with Supplementary Limb specimens had 1 failure at 1200 N. The difference in diastasis at the second metatarsal-medial cuneiform joint was statistically significant between the two groups at higher loads of 1600N (p = 0.019) and 1800N (p = 0.029).

CONCLUSION

The use of InternalBrace for ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early postoperative protected weight bearing. Furthermore, the use of a supplementary limb in addition to the InternalBrace fibertape fixation method appears to enhance its biomechanical efficacy.

Primary Arthrodesis for High-Energy Lisfranc Injuries

The reported incidence of Lisfranc injuries is 9.2/100.000 person-years; two-thirds of the injuries are nondisplaced. Tarsometatarsal injuries range from minor sprains and isolated ligamentous injuries to grossly unstable and multiligamentous lesions. High-energy injuries are usually linked with mechanical energy dissipation through the soft tissues. Operative treatment options include open reduction and internal fixation, open reduction with hybrid internal and external fixation, closed reduction with percutaneous internal or external fixation, and primary arthrodesis. Treatment goals are to obtain a painless, plantigrade, and stable foot. Anatomic reduction is a key factor for improved outcomes and decreased rates of post-traumatic arthritis.

Clinical study on the surgical treatment of atypical Lisfranc joint complex injury

BACKGROUND

Lisfranc injuries have not received much attention by orthopedic doctors in the past, and there is little related research on the diagnosis and treatment of these injuries. In recent years with the rise in foot and ankle surgery, doctors are now paying more attention to this type of injury. However, there is still a high rate of missed diagnosis due to insufficient attention causing treatment delays or inadequate treatments, which eventually result in greater sequelae; including long-term pain, arthritis, foot deformity etc. In particular, for cases with a mild Lisfranc joint complex injury, the incidence of sequelae is higher.

AIM

To select an active surgical treatment for an atypical Lisfranc joint complex injury and to evaluate the clinical efficacy of the surgical treatment.

METHODS

The clinical data of 18 patients, including 10 males and 8 females aged 20-64 years with Lisfranc injuries treated in our department from January 2017 to September 2019 were retrospectively analyzed. All patients were treated with an open reduction and internal fixation method using locking titanium mini-plates and hollow screws or Kirschner wires. X-ray images were taken and follow-up was performed monthly after the operation; the internal fixation was then removed 4-5 mo after the operation; and the American Orthopedic Foot and Ankle Society (AOFAS) score was used for evaluation on the last follow-up.

RESULTS

All patients were followed up for 6-12 mo. A good/excellent AOFAS score was observed in 88.9% of patients.

CONCLUSION

For atypical Lisfranc joint complex injuries, active open reduction and internal fixation can be performed to enable patients to obtain a good prognosis and satisfactory functional recovery.

Low-Energy Lisfranc Injuries: When to Fix and When to Fuse

Lisfranc injuries can be devastating to the athlete and nonathlete. In the athletic population, minor loss of midfoot stability compromises the high level of function demanded of the lower extremity. The most critical aspect of treatment is identifying the injury and severity of the ligamentous/articular damage. Not all athletes are able to return to their previous level of function. With appropriate treatment, a Lisfranc injury does not mandate the cessation of an athletic career. We focus on the diagnosis and an algorithmic approach to treatment in the athlete discussion the controversy of open reduction and internal fixation versus arthrodesis.

Dorsal bridge plating versus. Transarticular screw fixation for lisfranc injuries: A systematic review and meta-analysis

Lisfranc injuries are relatively uncommon but carry devastating consequences if left untreated. Although many surgical techniques have been proposed for best operative management, there is an ongoing debate over which procedure is superior. We performed a systematic review and meta-analysis comparing the outcomes of transarticular screw fixation and dorsal bridge plating in management of Lisfranc injuries. Ovid MEDLINE, Ovid Embase and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify randomised controlled trials (RCTs) and cohort studies comparing the outcomes between screw and dorsal plate fixation. The pooled outcome data were calculated by random and fixed effect models. One prospective cohort and three retrospective studies were identified with a total of 210 patients with mean follow up of 40.6 months. All papers were analysed for quality using the modified Newcastle Ottawa score. The results show that dorsal bridge plating is associated with better American Orthopaedic Foot and Ankle Society score (AOFAS) compared with transarticular screw fixation (OR - 0.71, 95% CI -1.31 to -0.10, p = 0.02). Dorsal plating may also be associated with fewer cases of arthritis, although this was not significant (OR 2.46, 95% CI 0.89 to 6.80, p = 0.08). We found no significant differences between the groups in terms of Foot Function Index (FFI), post traumatic arthritis and failure of hardware material. Although our results suggest dorsal bridge plating may provide superior functional outcomes, there is a scarcity of literature with little robustness to make definitive conclusions. High quality randomised trials are required.

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries

BACKGROUND

Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury.

METHODS

One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents.

RESULTS

Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45- 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003).

CONCLUSIONS

Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle.

LEVEL OF EVIDENCE

III.

Anatomy of the Lateral Plantar Ligaments of the Transverse Metatarsal Arch

BACKGROUND

While the anatomy of the Lisfranc complex is well understood, the lateral tarsometatarsal ligamentous structures, in contrast, are less well studied. Our aim in this study was to identify an anatomical explanation as to why the second to fifth metatarsals function as a unit in homolateral and divergent midfoot injuries.

METHODS

Eleven cadaveric lower limbs, preserved in formaldehyde, were examined at the University of Liverpool Human Anatomy and Resource Centre. Each of the lower limbs was dissected to identify the plantar aspect of the transverse metatarsal arch.

RESULTS

On removal of the long plantar ligament, the peroneal longus tendon was visible, as was its insertion onto the first metatarsal base. A lateral Lisfranc ligament (which was a transverse suspensory metatarsal ligament) spanned between the bases of the second and fifth metatarsals in all specimens with an average length of 33.7 mm and width of 4.6 mm. This ligament has not previously been described. It was noted that in all specimens, the long plantar ligament blended with the lateral Lisfranc ligament. In addition to the lateral Lisfranc ligament, separate intermetatarsal ligaments were identifiable connecting each metatarsal. The long plantar ligament provided a connection through the lateral Lisfranc ligament connecting the transverse and longitudinal arches of the foot.

CONCLUSION

We found a plantar ligament that provided connection through the long plantar ligament of both the transverse and the longitudinal arches. It spanned from the second to the fifth metatarsal, which we believe may explain that in some cases, lateral instability can be overcome when the middle column is stabilized.

CLINICAL RELEVANCE

We suspect that in the majority of homolateral and divergent types of tarsometatarsal injuries that the lateral Lisfranc ligament remains intact and thus it has significant clinical ramifications.

Incidence and Characteristics of Midfoot Injuries

BACKGROUND:

The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries (intra-articular injury in the tarsometatarsal joint) is 1/55 000 person-years and the incidence of Chopart injuries (intra-articular injury in the talonavicular and calcaneocuboidal joint) 4/100 000 person-years. The purpose of our study was to assess the computed tomography (CT) imaging-based incidence (per 100 000 person-years) and trauma mechanisms of midfoot injuries.

METHODS:

All CT studies performed due to acute injury of the foot and ankle region between January 1, 2012, and December 31, 2016, at Tampere University Hospital were reviewed. Patients presenting with an injury in the midfoot region in the CT scan were included in this study, and their records were retrospectively evaluated to assess patient characteristics.

RESULTS:

During the 5-year study period, 953 foot and ankle CT scans were obtained because of an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area, and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years.

CONCLUSIONS:

The incidence of Lisfranc injuries was higher and the incidence of Chopart injuries lower than previously estimated. More than two-thirds of the midfoot injuries in this study were nondisplaced (<2 mm displacement in fracture or joint) and were caused by low-energy trauma.

LEVEL OF EVIDENCE:

Level III, epidemiologic study.

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.

Subtle Lisfranc Injuries: A Topical Review and Modification of the Classification System

Lisfranc injuries are relatively uncommon. No specific incidence of subtle injuries has been reported; however, almost one-third are missed on initial review. These missed injuries are a common cause of litigation. Although seen in high-energy injuries with direct application of forces, they are also associated with lower-energy indirect mechanisms, often on the athletic field. This article provides a topical review of subtle Lisfranc disruptions, focusing on contemporary perspectives, and describes a modification to the most prevalent classification system. [Orthopedics. 2018; 41(2):e168-e175.].

Staged Management of Missed Lisfranc Injuries: A Report of Short-term Results

OBJECTIVE

Lisfranc joint injury is a rare injury and can be easily missed at the initial treatment. Once ignored, late reduction is very difficult and requires extensive dissection. Surgical outcome is not as good as in the case of an early reduction. The aim of this cohort study was to analyze the midterm clinical and radiographic outcomes of staged reduction and fixation in a consecutive series of patients with old Lisfranc injuries.

METHODS

Fifteen patients (16 feet) with missed Lisfranc injuries were treated with staged reduction. Mean duration between injury and surgery was 4.8 months (3-8 months). In the first stage, an external fixator was applied across the Lisfranc joint or/and Chopart joint and distraction was done at 1-2 mm/day. In the second staged, open reduction and internal fixation (ORIF) were done and we were able to reduce all the fractures and dislocations.

RESULTS

The mean duration between two surgeries was 3.2 weeks (range, 2.5-4.5 weeks). Anatomic reduction was obtained in all 15 patients. At the last follow-up point, 7 feet had good functional results, 5 feet fair, and 4 feet poor functional results. In the 4 patients who achieved poor functional results, 2 cases were due to severe injuries to the articular surface and tissue scaring; 2 cases were due to loss of reduction. For the 4 feet with poor functional results, 2 were scheduled for secondary arthrodesis during the follow-up. The average American Orthopaedic Foot and Ankle Society Midfoot Scale (AOFAS) scores for these patients were 75.8 points (range, 43-98 points). The pain visual analog scale (VAS) was 3.1 points at the final follow-up.

CONCLUSION

Our study demonstrated that staged reduction and extra-articular fixation should be considered for old Lisfranc injuries with a good reduction, firm stability, and low risk of intraoperative fracture and soft tissue complications.

Stability of Lisfranc injury fixation in Thiel Cadavers: Is routine fixation of the 1st and 3rd tarsometatarsal joint necessary?

BACKGROUND

There is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of the 4th & 5th tarsometatarsal joints is sufficient to stabilise Lisfranc injuries or if fixation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-articular plate which risk causing chondrolysis and/or osteoarthritis. The aims of this cadaveric study were to determine if routine fixation of the 1st and 3rd tarsometatarsal joints is necessary and to determine if a distal to proximal home run screw is adequate.

METHODS

Using 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displacement at each ray (1st-5th) and 1st-2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability.

RESULTS

At baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st-2nd intermetatarsal gap was 0mm. After transection of the Lisfranc ligament only, there was 1st-2nd intermetatarsal gaping (mean 4.5mm), but no increased dorsal displacement. After additional transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement.

CONCLUSIONS

The results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd-4th) are intact, the 3rd ray does not need to be routinely stabilised.

Functional Outcomes Post Lisfranc Injury-Transarticular Screws, Dorsal Bridge Plating or Combination Treatment?

OBJECTIVE

To identify whether transarticular screws, dorsal bridging plates or a combination of the 2 result in the best functional outcome after Lisfranc injury.

DESIGN

Case series.

SETTING

Level one trauma center.

PATIENTS

Fifty patients who underwent surgical fixation of Lisfranc injuries over a 6-year period were retrospectively reviewed.

INTERVENTION

One of 3 treatment arms: transarticular screw fixation alone, dorsal bridge plating alone or a combination of dorsal bridge and transarticular screw fixation.

MAIN OUTCOME MEASURES

The primary outcome measures were 1 of 2 midfoot scores-the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score and the Foot Function Index (FFI) Score. Secondary results included postoperative complications.

RESULTS

Quality anatomical reduction is the best predictor of functional outcomes (FFI-P = 0.008, AOFAS-P = 0.02). Functional outcomes with both FFI and AOFAS scores were not significantly associated with any of the fixation groups (FFI-P = 0.495, AOFAS-P = 0.654) on univariate analysis. Injury type by Myerson classification systems or open versus closed status was also not significantly associated with any fixation group. Open exposures were more likely to result in soft-tissue complications, but there was no significant difference in metalware failure or need for removal.

CONCLUSION

Functional outcomes after Lisfranc fractures are most dependant on the quality of anatomical reduction and not the choice of fixation implant used.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Do columns or sagittal displacement matter in the assessment and management of Lisfranc fracture dislocation? An alternate approach to classification of the Lisfranc injury

AIM

The classification of a Lisfranc injury has conventionally been based around Myerson's system. The aims of this study were to review whether a novel classification system based on sagittal displacement of the tarsometatarsal joint and breadth of injury as determined by a columnar theory was associated with functional outcomes and thus had a greater utility.

PATIENTS

We retrospectively reviewed 54 Lisfranc injuries with a minimum follow up of two years at our Level One Trauma Centre. Each fracture was sub-classified based on our novel classification system which assessed for evidence of sagittal displacement and involvement of columns of the midfoot. Our primary outcome measures were the FFI and AOFAS midfoot scores.

RESULTS

Injuries involving all three of the columns of the midfoot were associated with significantly worse functional outcome scores (FFI p=0.004, AOFAS p=0.036). Conversely, sagittal displacement, whether dorsal or plantar, had no significance (FFI p=0.147, AOFAS p=0.312). The best predictor of outcome was the quality of anatomical reduction (FFI p=0.008, AOFAS p=0.02).

CONCLUSION

Column involvement and not sagittal displacement is the most significant factor in considering the severity Lisfranc injury and long term functional outcomes. This classification system has greater clinical utility than those currently proposed.

Staged management of open Lisfranc injury: Experience from 14 patients

There are still controversies on the management and outcome of open Lisfranc injury in available studies. This study evaluates the staged management of Lisfranc injury and its complications.Patients who received a staged strategy for open Lisfranc injury were reviewed.One patient with degloving injury suffered from partial skin and hallux necrosis which was treated by debridement, hallux amputation, definitive internal fixation, and local flap transfer on the 12th day after first stage management. A definitive internal fixation and simultaneous skin graft or flap coverage were performed in another 3 patients with soft tissue defects. Other patients without soft tissue problems underwent a second stage of definitive internal fixation. Bone union was observed on the 12.5th week after definitive surgery. The median AOFAS midfoot score at the last follow-up was 74.4 ± 8.7, while the average VAS score was 2.2 ± 1.8. The average return-to-work time was 8th months postoperatively in 9 patients. Flap necrosis, infection, implant failure, nonunion, and osteomyelitis were not observed during the follow-up. Two patients received Lisfranc arthrodesis for persistent pain due to posttraumatic arthritis.In the management of open Lisfranc injury, surgeons must consider soft tissue condition. Staged strategy is a rational protocol for this severe injury. Temporary K-wire fixation after early radical debridement and realignment will facilitate the definitive internal fixation until soft tissue condition improves, which also can decrease the soft tissue complication.

Open Reduction and Internal Fixation Versus Primary Arthrodesis for Lisfranc Injuries

Management of injuries to the tarsometatarsal (Lisfranc) joint complex continues to generate heated debate. Arthrodesis of the Lisfranc joint complex has historically been reserved as a salvage procedure for failed treatment. Recently, primary arthrodesis has emerged as a viable treatment alternative to open reduction and internal fixation for these injuries. The objective of this article was to examine the current literature regarding open reduction and internal fixation versus primary arthrodesis of Lisfranc injuries.

An old mismanaged Lisfranc injury treated by gradual deformity correction followed by the second-stage internal fixation

The Lisfranc fracture-dislocation of the foot is uncommon and diagnosis is often missed. The Lisfranc joint involves the articulation between medial cuneiform and base of the second metatarsal and is considered a keystone to structural integrity to the midfoot. The articulation has a stabilization effect on longitudinal and transverse arches of the foot. A neglected or untreated injury to the Lisfranc joint can lead to secondary arthritis and significant morbidity and disability. We present a case of a neglected Lisfranc fracture-dislocation in a 28-year-old female patient who presented 3 months after injury. A staged treatment of distraction with an Ilizarov ring fixator followed in the second stage by the removal of ring fixator and internal fixation with K wires was performed. There was complete relief of pain and a good functional outcome at 3 months after treatment.

Functional Outcomes After Temporary Bridging With Locking Plates in Lisfranc Injuries

The standard operative treatment of Lisfranc fracture dislocations currently consists of open reduction and transarticular fixation. Recently, bridge plating has been used more often. Using joint spanning, the reduced fracture dislocation is temporary stabilized to minimize articular damage. The present study describes the outcomes of patients treated with bridge plating after tarsometatarsal fracture dislocations compared with transarticular screw fixation. A retrospective cohort study was performed. Patients with an isolated tarsometatarsal injury who had been treated operatively from June 2000 to October 2013 were included. The primary functional outcome was measured using the American Orthopaedic Foot and Ankle Society midfoot score and the Foot Function Index. The secondary outcome was patient satisfaction, which was measured using the EuroQol 5 dimensions questionnaire and a visual analog scale. A total of 34 patients were included. Bridge plating was used in 21 patients. In 13 patients, Kirschner wires or transarticular screws or a combination were used. The median follow-up period was 49 (interquartile range 18 to 89) months. The implants were removed in 10 of 13 patients in the transarticular group and 17 of 21 patients in the bridge plating group. The incidence of wound complications was comparable in both groups. The median American Orthopaedic Foot and Ankle Society score was lower in the transarticular group (77 versus 66). The Foot Function Index score was 18 in both groups. Patient satisfaction was 90% in the bridge plating group and 80% in the transarticular group. Bridge plating for Lisfranc injuries led to at least similar results compared with transarticular fixation in terms of functional outcomes and patient satisfaction. Longer follow-up is necessary to determine whether the prevention of secondary damage to the articular surface leads to less post-traumatic arthritis and better functional outcomes.

Current Swiss Techniques in Management of Lisfranc Injuries of the Foot

The outcome after Lisfranc injuries correlates with anatomic and stable reduction. The best surgical treatment, particularly for the ligamentous Lisfranc injuries, remains controversial. Recent publications suggest that the ligamentous injuries may benefit from primary partial Lisfranc arthrodesis. Most surgeons agree that an appropriate reduction is better and easier achieved by open reduction and stable temporary screw or dorsal plate fixation or by open primary partial arthrodesis than by closed reduction or Kirschner wire fixation. Despite correct surgical technique and postoperative management, symptom-free recovery is uncommon. This article outlines current techniques in the management of Lisfranc injuries and resultant postoperative outcomes in a level I trauma center.

Minimally Invasive Medial Plating of Low-Energy Lisfranc Injuries: Preliminary Experience with Five Cases

Fracture dislocations involving the Lisfranc joint are rare; they represent only 0.2% of all the fractures. There is no consensus about the surgical management of these lesions in the medical literature. However, both anatomical reduction and tarsometatarsal stabilization are essential for a good outcome. In this clinical study, five consecutive patients with a diagnosis of Lisfranc low-energy lesion were treated with a novel surgical technique characterized by minimal osteosynthesis performed through a minimally invasive approach. According to the radiological criteria established, the joint reduction was anatomical in four patients, almost anatomical in one patient (#4), and nonanatomical in none of the patients. At the final follow-up, the AOFAS score for the midfoot was 96 points (range, 95-100). The mean score according to the VAS (Visual Analog Scale) at the end of the follow-up period was 1.4 points over 10 (range, 0-3). The surgical technique described in this clinical study is characterized by the use of implants with the utilization of a novel approach to reduce joint and soft tissue damage. We performed a closed reduction and minimally invasive stabilization with a bridge plate and a screw after achieving a closed anatomical reduction.

Joint-sparing Corrections in Malunited Lisfranc Joint Injuries

Lisfranc fracture-dislocations are very serious and potentially disabling injuries. Unfortunately, they are often misdiagnosed. Multiplanar midfoot deformities that result from these fracture-dislocations are precursors of joint degeneration and significant functional disabilities. Anatomic reduction with different types of internal fixation is an efficient method to reconstruct midfoot alignment and stability. Joint-preserving reconstruction techniques emerge as a viable alternative to corrective fusion as they achieve stable joint realignment with preserved motion.

Temporary Internal Fixation for Ligamentous and Osseous Lisfranc Injuries: Outcome and Technical Tip

BACKGROUND

Open rather than closed reduction and internal fixation as well as primary definitive arthrodesis are well accepted for ligamentous and osseous Lisfranc injuries. For ligamentous injuries, a better outcome after primary definitive partial arthrodesis has been published.

METHODS

Of 135 Lisfranc injuries that were treated from 1998 to 2012 with open reduction, temporary internal fixation by screws and plates, and restricted weight bearing in a lower leg cast for 3 months followed by an arch support for another 4 to 6 weeks, 29 ligamentous Lisfranc injuries were available for follow-up. They were compared with 29 osseous Lisfranc injuries matched in age and gender.

RESULTS

Between the groups, there were no significant differences in average age (39.9 vs 38 years) or in average follow-up time (8.3 vs 9.1 years). Also, no significant differences were seen in the AOFAS midfoot score (84 vs 85.3 points), the FFI pain scale (9.9 vs 14.9 points), SF 36 physical component (56.2 vs 53.9 points), SF 36 mental component (57 vs 56.4 points), or VAS for pain (1.6 vs 1.5 points). The FFI function scale was significantly lower in the ligamentous group (11.6 vs 19.5 points). Radiographically, loss of reduction was recorded 3 times in the ligamentous injuries and 4 times in the osseous injuries. Arthritis was mild/moderate/severe in 5/3/0 ligamentous injuries and in 7/2/1 osseous injuries, requiring 1 definitive secondary Lisfranc arthrodesis in each group.

CONCLUSION

With longer and conservative postoperative management, open reduction and temporary internal fixation in ligamentous and osseous Lisfranc injuries led to equal medium-term outcome. Inferior outcome in ligamentous injuries was not found.

LEVEL OF EVIDENCE

Level III, retrospective comparative cohort study.

[Anatomical reconstruction of chronically instable Lisfranc's ligaments]

BACKGROUND

From June 2001 to May 2013 four selected patients with an isolated and old Lisfranc's ligament rupture were treated at the Trauma Department of the University Hospital Carl Gustav Carus in Dresden with an anatomical repair of the ligament using half of the extensor hallucis longus tendon. This kind of graft 7 cm in length was used in three cases and in the fourth case the whole extensor hallucis brevis tendon was used. Of the four patients three were female with an average age of 28.6 years (range 15-39 years). The fourth patient was a 23-year-old male who was followed up for only 3 months due to emigration abroad. The three female patients were postoperatively followed up for a minimum of 1 year clinically and at the 1 year follow-up all three women had a stable Lisfranc's joint, two were absolutely pain free and one was relatively pain free.

RESULTS

The youngest of the three females was 15 years old at the time of surgery and in preparation for the Olympic Games as a gymnast. This gave rise to the idea for an anatomical repair to avoid partial fusion of the Lisfranc's joint in this very young and extremely competitive sportswoman. The Lisfranc's joint was completely stable and pain free 2 years postoperatively and 10 years after surgery she qualified for the 2005 World Championships in Australia and the Olympic Games in Beijing in 2008.

Staged treatment of high energy midfoot fracture dislocations

BACKGROUND

Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious.

METHODS

One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed.

RESULTS

The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred.

CONCLUSION

Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Lisfranc injuries: an update

Lisfranc injuries are a spectrum of injuries to the tarsometatarsal joint complex of the midfoot. These range from subtle ligamentous sprains, often seen in athletes, to fracture dislocations seen in high-energy injuries. Accurate and early diagnosis is important to optimise treatment and minimise long-term disability, but unfortunately, this is a frequently missed injury. Undisplaced injuries have excellent outcomes with non-operative treatment. Displaced injuries have worse outcomes and require anatomical reduction and internal fixation for the best outcome. Although evidence to date supports the use of screw fixation, plate fixation may avoid further articular joint damage and may have benefits. Recent evidence supports the use of limited arthrodesis in more complex injuries.

Technique tip: percutaneous fixation of partial incongruous Lisfranc injuries in athletes

Open reduction with screw fixation is considered the standard surgical approach for injuries of the Lisfranc complex in athletes. However, multiple incisions are required, which increase the risk for postoperative complications. We present a novel percutaneous reduction and solid screw fixation technique that may be a viable option to address partial incongruous injuries of the Lisfranc complex in athletes. At our institution, no intraoperative or postoperative complications have been encountered. Screw breakage did not occur. Reduction of the second metatarsal was considered anatomic across all patients. All patients have returned to their respective sport without limitation. The percutaneous approach appears to decrease complications while the targeting-reduction guide appears to precisely reduce the injury. Consequently, outcomes have been more consistent and predictable. The authors note that this percutaneous approach is specific to partial incongruous injuries of the Lisfranc complex. When presented with more extensive injuries, the authors advocate an open approach.

Three-dimensional, digital, and gross anatomy of the Lisfranc ligament

BACKGROUND

There are inconsistencies in the descriptive anatomy of the Lisfranc ligament. No information is available on orientation of fibers or presence of bundles, nor are there 3-dimensional anatomic data on the ligaments or their attachments. This study assessed the 3-dimensional anatomy of the Lisfranc ligament and its attachment sites.

METHODS

A total of 37 cadaver feet were dissected to expose the ligament attachments at the Lisfranc joint. The Lisfranc ligament and plantar ligament attachments were outlined separately and then removed with the attachment outlines preserved. A 3-dimensional digitizer was used to digitize bony and articular surfaces, as well as ligament attachment sites, at approximately 1 mm intervals; the positional accuracy was 0.23 mm. The surface areas of the entire bone, articular regions, and Lisfranc and plantar ligament attachment regions were determined and anatomic details were noted.

RESULTS

The Lisfranc ligament had a single bundle in 73% of the specimens and 2 bundles in 27%. Both variations had a single attachment to the second metatarsal (M2; mean attachment surface area, 135 mm(2)). The single-bundle variation attached to the medial cuneiform (C1; mean attachment surface area, 140 mm(2)). The plantar ligament, C1-M2-M3, attached to the anterior plantar surface of the lateral aspect of C1 (mean attachment surface, 64 mm(2)) and had attachment sites at the bases of M2 and M3. Its fibers ran anteriorly and inferiorly, with attachments to the proximal inferomedial aspect of M2 (mean attachment surface, 63 mm(2)) and fibers extending to a smaller attachment at the plantar aspect of M3 (mean attachment surface area, 26 mm(2)).

CONCLUSION

The Lisfranc ligament is variable in anatomy and can have a single- or double-bundle arrangement. Its area of attachment is larger than that of the plantar ligament.

CLINICAL RELEVANCE

Anatomic descriptions of location, dimensions, and variability in the position and surface area of the ligament attachment sites and of orientation of the bundles provide information for future attempts at repair or reconstruction of the Lisfranc ligament.

Influence of approach and implant on reduction accuracy and stability in lisfranc fracture-dislocation at the tarsometatarsal joint

BACKGROUND

Besides early diagnosis, an anatomical and stable reduction is paramount for obtaining a favorable outcome. The current study looked at the influence that the type of approach for tarsometatarsal injuries has on the accuracy of the reduction and the effect that the type of fixation has on stability.

METHODS

Consecutive patients treated surgically for an acute Lisfranc injury were included. All radiographs were reassessed for accuracy and secondary displacement following either a closed or an open approach and in terms of the type of fixation (Kirschner wires alone or a combination of screws and plates and Kirschner wires). A total of 28 patients were included. Six patients were treated with closed reduction and percutaneous fixation and 22 with open reduction internal fixation. Sixteen patients were treated with Kirschner wires only (6 closed, 10 open), 7 with screws with or without Kirschner wires, and 5 with medial plating with or without Kirschner wires.

RESULTS

In the closed reduction group, 2 of 6 (33%) reductions were considered acceptable versus 19 of 22 (86%) in the open group (P = .021). All 6 secondary displacements occurred in the Kirschner wire fixation group (37.5%) versus none in the rigid fixation group (P = .024).

CONCLUSION

The results demonstrate that open reduction and internal fixation with screws or plate resulted in better reduction and better maintenance of reduction in both low- and high-energy Lisfranc injuries. These results should be further evaluated in light of functional outcome.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Subtle injuries to the lisfranc joint

The tarsometatarsal joint complex is an osseous and capsuloligamentous network that includes the 5 metatarsals, their articulations with the cuneiforms and cuboid, and the Lisfranc ligament, a strong interosseous attachment between the medial cuneiform and second metatarsal. A multitude of injury patterns exist involving the tarsometatarsal joint complex; a Lisfranc injury does not delineate a specific injury, but instead a spectrum of processes involving the tarsometatarsal joint complex.

Long-term outcome of high-energy open Lisfranc injuries: a retrospective study

BACKGROUND

The outcome of open Lisfranc injuries has been reported infrequently. Should these injuries be managed as closed injuries and is their outcome different?

METHODS

We undertook a retrospective study of high-energy, open Lisfranc injuries treated between 1999 and 2005. The types of dislocation, the associated injuries to the same foot, the radiologic and functional outcome, and the complications were studied. There were 22 patients. Five patients died. One had amputation. Of the remaining 16 patients, 13 men were followed up at a mean of 56 months (range, 29-88 months). The average age was 36 years (range, 7-55 years).

RESULTS

According to the modified Hardcastle classification, type B2 injury was the commonest. Ten patients had additional forefoot or midfoot injury. All patients were treated with debridement, open reduction, and multiple Kirschner (K) wire fixation. All injuries were Gustilo Anderson type IIIa or IIIb. Nine patients had split skin graft for soft tissue cover. Mean time taken for wound healing was 16 days (range, 10-30 days). Ten patients (77%) had fracture comminution. Eight patients had anatomic reduction, whereas five had nonanatomic reduction. Ten of 13 (77%) patients had at least one spontaneous tarsometatarsal joint fusion. The mean American Orthopaedic Foot and Ankle Society score was 82 (range, 59-100). Nonanatomic reduction, osteomyelitis, deformity of toes, planus foot, and mild discomfort on prolonged walking were the unfavorable outcomes present.

CONCLUSION

In open Lisfranc injuries, multiple K wire fixation should be considered especially in the presence of comminution and soft tissue loss. Although anatomic reduction is always not obtained, the treatment principles should include adequate debridement, maintaining alignment with multiple K wires, and obtaining early soft tissue cover. There is a high incidence of fusion across tarsometatarsal joints.

Lisfranc joint ligamentous complex: MRI with anatomic correlation in cadavers

OBJECTIVE

The aim of our study was to clarify the ligamentous anatomy of the Lisfranc joint complex and show the diagnostic capability of MRI in the assessment of the Lisfranc joint complex with detailed anatomic correlation in cadavers.

MATERIALS AND METHODS

Ten fresh cadaveric feet were studied with high-spatial-resolution MRI before and after the intraarticular injection of a gadopentetate dimeglumine solution. MR images were evaluated by two readers in consensus, with emphasis on the visibility of the ligamentous structures and their appearance. Readers also measured the dimensions (length, width, and thickness) of the Lisfranc ligament and of the first plantar tarsometatarsal ligament, or plantar Lisfranc ligament. For anatomic analysis, nine cadaveric specimens were sectioned in 3-mm-thick slices in the same planes used during MRI. One additional foot specimen was used for dissection.

RESULTS

In all 10 cadaveric specimens we were able to identify and characterize with MRI the different ligamentous elements that contribute to the overall stability of the Lisfranc joint complex.

CONCLUSION

By clearly defining the normal ligaments that contribute to the stability of the Lisfranc joint, MRI allows a more precise and correct diagnosis of the origin of the Lisfranc joint instability, perhaps permitting a more specific surgical management. MRI also allows a better understanding of the normal imaging anatomy of the different ligamentous components of the Lisfranc joint, mainly of the Lisfranc and plantar Lisfranc ligaments.

Treatment of Lisfranc joint injury: current concepts

Injuries to the tarsometatarsal joint complex, also known as the Lisfranc joint, are relatively uncommon. However, the importance of an accurate diagnosis cannot be overstated. These injuries, especially when missed, may result in considerable long-term disability as the result of posttraumatic arthritis. A high level of suspicion, recognition of the clinical signs of injury, and appropriate radiographic studies are needed for correct diagnosis. When surgery is indicated, closed reduction with percutaneous screw fixation should be attempted. If reduction is questionable, open reduction should be performed. Screw fixation remains the traditional fixation technique.

Risk management and avoiding legal pitfalls in the emergency treatment of high-risk orthopedic injuries

Avoiding legal pitfalls of orthopedic injuries in the emergency department (ED) requires an understanding of certain high-risk injuries, their presentation, evaluation, and disposition. Various pitfalls pertaining to both upper and lower extremity injuries are discussed in detail, with recommendations regarding the history, physical examination, and radiographic techniques that minimize the risk inherent in these injuries. When approaching these injuries in the ED, a high level of suspicion coupled with appropriate evaluation and management will allow the practitioner to avoid mismanagement of these potential pitfall cases.