Stability of Lisfranc joints in ballet pointe position

Patient-Reported Outcome Measures After Surgical Management of Unstable Lisfranc Injuries in Athletes

Background:

Athletes sustaining Lisfranc joint instability after a low-energy injury often undergo surgical fixation. Limited studies report validated patient-reported outcome measures (PROMs) for this specific patient population. Our purpose was to report PROMs of athletes experiencing instability after a low-energy Lisfranc injury and undergoing surgical fixation.

Methods:

Twenty-nine athletes (23 competitive, 6 recreational) sustained an unstable Lisfranc injury (14 acute, 15 chronic) and met our inclusion criteria. Injuries were classified as acute if surgically managed within 6 weeks. All athletes completed validated PROMs pre- and postoperatively. The cohort underwent various open reduction internal fixation methods. We evaluated outcomes with the Foot and Ankle Ability Measure (FAAM) activities of daily living (ADL) and sports subscales.

Results:

Fourteen of 29 (48%) athletes reported PROMs at ≥2 years with a median follow-up time of 44.5 months. Substantial improvement for both FAAM ADL (50% vs 93%; P < .001) and sports (14.1% vs 80%; P = .002) subscales were found, when comparing preoperative to postoperative scores at ≥2 years.

Conclusion:

This study provides outcomes information for the young athletic population that were treated operatively for low-energy Lisfranc injury with apparent joint instability. Based on the FAAM sports subscale, these patients on average improved between their 6-month evaluation and their final ≥2 years but still scored 80% of the possible 100%, which indicates continued but “slight” difficulty with lower extremity function.

Level of Evidence:

Level IV, case series.

Applications of Biomechanical Foot Models to Evaluate Dance Movements Using Three-Dimensional Motion Capture: A Review of the Literature

Dance movement requires excessive, repetitive range of motion (ROM) at the foot-ankle complex, possibly contributing to the high rate of injury among dancers. However, we know little about foot biomechanics during dance movements. Researchers are using three-dimensional (3D) motion capture systems to study the in vivo kinematics of joint segments more frequently in dance-medicine research, warranting a literature review and quality assessment evaluation. The purpose of this literature review was to identify and evaluate studies that used 3D motion capture to analyze in vivo biomechanics of the foot and ankle for a cohort of dancers during dance-specific movement. Three databases (PubMed, Ovid MEDLINE, CINAHL) were accessed along with hand searches of dance-specific journals to identify relevant articles through March 2020. Using specific selection criteria, 25 studies were identified. Fifteen studies used single-segment biomechanical foot models originally created to study gait, four used a novel two-segment model, and six utilized a multi-seg- ment foot model. Nine of the studies referenced common and frequently published gait marker sets and four used a dance-specific biomechanical model with purposefully designed foot segments to analyze the dancers' foot and ankle. Description of the biomechanical models varied, reducing the reproducibility of the models and protocols. Investigators concluded that there is little evidence that the extreme total, segmental, and inter-segmental foot and ankle ROM exerted by dancers are being evaluated during dance-specific movements using 3D motion capture. Findings suggest that 3D motion capture is a robust measurement tool that has the capability to assist researchers in evaluating the in vivo, inter-segmental motion of the foot and ankle to potentially discover many of the remaining significant factors predisposing dancers to injury. The literature review synthesis is presented with recommendations for consideration when evaluating results from studies that utilized a 3D biomechanical foot model to evaluate dance-specific movement.

Anatomical Pathology of Subtle Lisfranc Injury

The extent and patterns of Lisfranc joint complex disruption in subtle Lisfranc injuries have not been well clarified. We reviewed the direct intraoperative findings for 87 patients, examined computed tomography images that had been obtained preoperatively for 73 of the patients, and classified the injuries according to the Kaar  et al. criteria as the transverse type (instability between the first cuneiform [C1] and the second metatarsal [M2] and between the second cuneiform [C2] and M2) or longitudinal type (instability between C1 and M2 and between C1 and C2). Our patients’ injuries were classified as follows: longitudinal type (38%), transverse type (30%), transverse type and first tarsometatarsal (TMT) joint injury (20%), longitudinal type plus transverse type (7%), longitudinal type and first TMT joint injury (3%), and longitudinal type, transverse type, and first TMT joint injury (2%). In 11 patients, the longitudinal injury extended into the naviculo-first cuneiform joint. In 41 (56%) of the 73 patients for whom CT images were obtained, 1 or more fractures (not counting small avulsion fragments between C1 and M2) were found. Orthopedic surgeons should be aware of the various injury patterns possible in cases of subtle Lisfranc injury.

Acute Effect of Toe Cap Choice on Toe Deviation Angle and Perceived Pain in Female Professional Ballet Dancers

Several classical dance complex movements, such as pointe, require body weight to be supported properly to avoid risk of foot injury. Regarding the choice of toe cap for pointe shoes, it is unclear which type can better alleviate pain symptoms and toe deviation angle in dancers. The aim of the current crossover study was to investigate the acute effect of using different types of toe caps among well-trained professional dancers on pain perception and toe deviation angle. Ten young female professional dancers volunteered to participate in the study. Each participant was tested during two separate sessions with an interval of 72 h in between. Participants were tested in the two sessions with a standard commercial or a customized prototype toe cap, always with pointe shoes, and in randomized order. An anteroposterior X-ray examination was performed separately for each participant and a visual analogue scale for pain perception was administered following each situation (with a standard commercial or a customized prototype toe cap). Significant amelioration was obtained when a customized toe cap prototype was used both for toe deviation angle and for visual analogue scale. Use of a customized toe cap prototype compared to a standard one may acutely reduce both toe deviation angle and pain in elite female professional dancers.

Lisfranc injury: assessment and management in emergency departments

Injuries to the tarsometatarsal joint complex, also referred to as a Lisfranc injury, are relatively uncommon presentations to emergency departments (EDs), however accurate diagnosis is vital to prevent the risk of long-term disability. Advanced nurse practitioners (ANPs) must use a broad range of clinical skills to manage patients' injuries effectively. A high level of suspicion, recognition of the clinical manifestations of Lisfranc injury and appropriate radiographic images are required to formulate a correct diagnosis. This article describes Lisfranc injuries, revises the anatomy of the midfoot, and discusses diagnosis and management. It includes a case study to illustrate assessment and management of a patient who presented to an ED with a Lisfranc injury following a fall from a height and considers the diagnostic decisions and management options available to ANPs.

Still Human: A Call for Increased Focus on Ethical Standards in Cadaver Research

Research on human cadavers is an important mechanism of scientific progress and comprises a large industry in the United States. However, despite its importance and influence, there is little ethical or regulatory oversight of cadaver-based research. This lack of transparency raises important ethical questions. Thus, this paper serves as a call for ethicists and regulators to pay increased attention to cadaver research. I argue that cadaver research ought to be considered a subset of human subjects research and held accountable to higher ethical standards. After describing current practices, I argue that oversight of cadaver research as a form of human subjects research is appropriate because cadaver research is similar to other types of human research, participants in cadaver research incur risks of harm, and a current lack of oversight has allowed the cadaver industry to entice research participation through ethically questionable practices. This paper urges greater dialogue among human subjects research ethicists and regulators about what constitutes appropriate protections for participants in cadaver research.

Lower Extremity Injury Patterns in Elite Ballet Dancers: Ultrasound/MRI Imaging Features and an Institutional Overview of Therapeutic Ultrasound Guided Percutaneous Interventions

BACKGROUND

Altered biomechanics from repetitive microtrauma, such as long practice hours in en pointe (tip of the toes) or demi pointe (balls of the feet) predispose ballet dancers to a multitude of musculoskeletal pathologies particularly in the lower extremities. Both ultrasound and magnetic resonance imaging (MRI) are radiation-sparing modalities which can be used to confidently evaluate these injuries, with ultrasound (US) offering the added utility of therapeutic intervention at the same time in experienced hands.

QUESTIONS/PURPOSES

The purposes of this paper were: (1) to illustrate the US and MRI features of lower extremity injury patterns in ballet dancers, focusing on pathologies commonly encountered at a single orthopedic hospital; (2) to present complementary roles of both ultrasound and MRI in the evaluation of these injuries whenever possible; (3) to review and present our institutional approach towards therapeutic ultrasound-guided interventions by presenting explicit cases.

METHODS

Online searches were performed using the search criteria of "ballet biomechanics" and "ballet injuries." The results were then further narrowed down by limiting articles published in the past 15 years, modality (US and MRI), anatomical region (foot and ankle, hip and knee) and to major radiology, orthopedics, and sports medicine journals.

RESULTS

Performing ballet poses major stress to lower extremities and predisposes dancer to several musculoskeletal injuries. These can be adequately evaluated by both US and MRI. US is useful for evaluating superficial structures such as soft tissues, tendons, and ligaments, particularly in the foot and ankle. MRI provides superior resolution of deeper structures such as joints, bone marrow, and cartilage. In addition, US can be used as a therapeutic tool for providing quick symptomatic improvement in these athletes for who "time is money".

CONCLUSION

Performing ballet may cause major stress to the lower extremities, predominantly affecting the foot and ankle, followed by the knee and hip. US and MRI play complementary roles in evaluating various orthopedic conditions in ballet dancers, with US allowing for dynamic evaluation and guidance for interventions.

Lisfranc injuries

Lisfranc injuries are commonly asked about in FRCS Orthopaedic trauma vivas. The term "Lisfranc injury" strictly refers to an injury where one or more of the metatarsals are displaced from the tarsus. The term is more commonly used to describe an injury to the midfoot centred on the 2nd tarsometatarsal joint. The injury is named after Jacques Lisfranc de St. Martin (1790-1847), a French surgeon and gynaecologist who first described the injury in 1815. 'Lisfranc injury' encompasses a broad spectrum of injuries, which can be purely ligamentous or involve the osseous and articular structures. They are often difficult to diagnose and treat, but if not detected and appropriately managed they can cause long-term disability. This review outlines the anatomy, epidemiology, classification, investigation and current evidence on management of this injury.

Preventing dance injuries: current perspectives

Dancers are clearly athletes in the degree to which sophisticated physical capacities are required to perform at a high level. The standard complement of athletic attributes - muscular strength and endurance, anaerobic and aerobic energy utilization, speed, agility, coordination, motor control, and psychological readiness - all are essential to dance performance. In dance, as in any athletic activity, injuries are prevalent. This paper presents the research background of dance injuries, characteristics that distinguish dance and dancers from traditional sports and athletes, and research-based perspectives into how dance injuries can be reduced or prevented, including the factors of physical training, nutrition and rest, flooring, dancing en pointe, and specialized health care access for dancers. The review concludes by offering five essential components for those involved with caring for dancers that, when properly applied, will assist them in decreasing the likelihood of dance-related injury and ensuring that dancers receive optimum attention from the health care profession: (1) screening; (2) physical training; (3) nutrition and rest; (4) specialized dance health care; and (5) becoming acquainted with the nature of dance and dancers.

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

Although Lisfranc injuries are uncommon, prompt and accurate diagnosis of such injuries in athletes is essential in preventing career-ending injury. Undisplaced injuries have an excellent result with nonoperative treatment. The presence of any displacement warrants open reduction and anatomic fixation; although current evidence mostly supports screw fixation, plate fixation may avoid joint intrusion. It is imperative to warn athletes with significantly displaced injuries that there is a risk of a poor outcome, although some recent evidence suggests that return to elite competitive sports is still likely after surgical intervention. Severe injuries may have better outcomes with limited arthrodesis.

Lisfranc injuries in sport

Injuries to the Lisfranc ligament complex have traditionally been associated with high energy trauma such as motor vehicle collisions and industrial accidents. Recently, there has been a greater appreciation of mid-foot sprains that represent a spectrum of injury to the Lisfranc ligament complex. As a result, there has been an increased incidence of such injury resulting from low-energy trauma in activities ranging from recreational activity to elite athletic activity. This article discusses issues related to anatomy, clinical presentation, mechanism of injury, and diagnosis that are necessary to provide appropriate treatment for these injuries. There should be a high index of suspicion of this injury, and prompt diagnosis is important to allow athletes to return to sport with the best possible outcome.

Stress fractures of the base of the metatarsal bones in young trainee ballet dancers

Classical ballet is an art form requiring extraordinary physical activity, characterised by rigorous training. These can lead to many overuse injuries arising from repetitive minor trauma. The purpose of this paper is to report our experience in the diagnosis and treatment of stress fractures at the base of the second and third metatarsal bones in young ballet dancers. We considered 150 trainee ballet dancers from the Ballet Schools of "Teatro Alla Scala" of Milan from 2005 to 2007. Nineteen of them presented with stress fractures of the base of the metatarsal bones. We treated 18 dancers with external shockwave therapy (ESWT) and one with pulsed electromagnetic fields (EMF) and low-intensity ultrasound (US); all patients were recommended rest. In all cases good results were obtained. The best approach to metatarsal stress fractures is to diagnose them early through clinical examination and then through X-ray and MRI. ESWT gave good results, with a relatively short time of rest from the patients' activities and a return to dancing without pain.

A minimally disruptive model and three-dimensional evaluation of Lisfranc joint diastasis

BACKGROUND

There is no model that can reproduce the diastasis at the Lisfranc joint after isolated transection of the Lisfranc ligament. Prior models required extensive sectioning of ligaments in the midfoot and represent injuries that cause extensive tarsometatarsal fracture-dislocations. They do not represent a subset of injuries that cause subtle or limited disruption at the Lisfranc joint. The purpose of this study was to create a model with the minimum amount of ligamentous disruption and loading necessary to consistently observe diastasis at the Lisfranc joint.

METHODS

Fourteen fresh-frozen paired cadaver feet were dissected to expose the dorsum. Three screws were inserted into each first cuneiform and second metatarsal to create a pair of registration triads. A digitizer was utilized to record the three-dimensional positions of the screws and their displacement under loaded and unloaded conditions before and after the Lisfranc ligament was cut (intact and cut conditions). The first and second cuneiforms and their metatarsals were removed, and the attachment sites of the dorsal and the Lisfranc ligament were digitized. The three-dimensional positions of the bones and ligament displacement were determined. The significance of differences between conditions was tested with analysis of variance, and linear regression analysis was used to test the correlation between dorsal and plantar displacements.

RESULTS

There was a significant difference, of 1.3 mm, in the mean displacement between the cut loaded and intact loaded conditions (p < 0.0001). A modest correlation (r(2) = 0.60) was found between dorsal displacement and displacement at the site of the Lisfranc ligament, possibly attributable to rotations between the first cuneiform and second metatarsal.

CONCLUSIONS

Isolated sectioning of the Lisfranc ligament is sufficient to consistently create diastasis at the Lisfranc joint. Dorsal displacements between the first cuneiform and second metatarsal are a modest predictor of plantar displacements.

[Weight bearing upright magnetic resonance imaging of pointe dancing]

Weight-bearing upright Magnetic resonance imaging (MRI) "en pointe" is the ideal tool for research in the field of functional anatomy of pointe dancing and pointe dancing related medicine.

Stress fractures of the second metatarsal base occur in nondancers

Stress fractures of the base of the second metatarsal are common in ballet dancers and essentially are unreported in nondancers. We presumed base of the second metatarsal stress fractures in nondancers occur in a wide variety of individuals regardless of demographics, are highly associated with athletic activities, and have specific examination findings and poor clinical outcomes. Using a retrospective chart review, we identified 12 stress fractures at the base of the second metatarsal (nine patients) in nondancers. Our review suggests second metatarsal base stress fractures occur in nondancers in a diverse population, and nonoperative treatment provides limited success. Advanced radiographic study, specifically MRI, is useful to assist the early diagnosis and prognostication. All of the stress fractures were treated nonoperatively; six fractures (50%) developed nonunion and five underwent subsequent surgery. The surgery for nonunion provided successful outcomes; however, risk factors such as low bone mass and comorbidities may have played important roles in the prognosis.

Foot and Ankle Injuries in Dance

Although dancers develop overuse injuries common in other athletes, they are also susceptible to unique injuries. This article reviews common foot and ankle problems seen in dancers and provides some basic diagnosis and treatment strategies.

Dance-Related Injury

Although dance medicine has derived extensive knowledge from sports medicine, some aspects covered in the practice of dance medicine are unique to this field. Acute and overuse injuries must be analyzed within the scope of associated mechanisms of injury, mainly related to the practice of specific dance techniques. Even though most available medical literature concerning dance medicine is specific to ballet-related conditions, many of the concepts covered here and in other articles can be helpful in the treatment and diagnosis of participants in other dance disciplines. Continued research is expanding the knowledge on injury patterns of different dance disciplines. It is the experience of dance practitioners that dancers are quite in touch with their bodies; thus, when their ailments are systematically analyzed, and underlying cause can usually be identified. In this sense, it is evident that the principles of dance medicine and rehabilitation allow the practitioner to arrive at a diagnosis and treat the underlying causes to prevent reinjury, ameliorate sequelae from injury, and minimize residual deficits after injury.

Lisfranc fracture-dislocations: current treatment and new surgical approaches

Anatomic reduction and restoration of the acute or chronic fracture-dislocation of the tarso-metatarsal joint is essential and needs to be addressed early in the patient's treatment with internal or external fixation. Long-term results following this injury can be associated with chronic instability, posttraumatic arthrosis, and poor functional outcomes. In this article, the authors review the current treatments of internal fixation and introduce new surgical techniques for addressing the acute or chronic tarso-metatarsal injuries with the application of circular multiplane external fixation devices.