Lisfranc Injuries in the Athlete

Comparison of diagnostic performance of X‑ray, CT and MRI in patients with surgically confirmed subtle Lisfranc injuries

The present study aimed to compare the diagnostic performance of three imaging tests: X-ray, computed tomography (CT) and magnetic resonance imaging (MRI), for subtle Lisfranc injuries and three anatomical subtype injuries. The non-weight-bearing X-ray, CT and MRI imaging results of patients with subtle Lisfranc injuries from September 2013 to March 2022 were retrospectively reviewed. Subtle Lisfranc injuries and three anatomical subtypes (first, second and cuneiform rays) were diagnosed based on the surgical reports. The diagnostic performance of X-ray, CT and MRI was compared. The sensitivity (Sn), specificity (Sp), positive predictive value, negative predictive value, area under the receiver operating characteristic curve (AUC) and κ coefficient were reported. A total of 31 patients were included in the study. The correct diagnosis was made in 48.4% (15/31), 87.1% (27/31) and 96.8% (30/31) of patients by X-ray, CT and MRI, respectively. A total of 54 different anatomical injuries were found intraoperatively in all patients, with MRI and CT having high agreement (Sn, 72.2 and 87.0%; κ, 0.69 and 0.78, respectively) and X-ray having a low agreement (Sn, 29.6%; κ, 0.26) with the surgical findings. Regarding the first-ray injuries, CT had the highest Sn (76.9%), Sp (100%) and AUC (0.885) in diagnosing subtle Lisfranc injuries. MRI showed the best Sn (88.5 and 93.3%, respectively) and AUC (0.942 and 0.904, respectively) in both second and cuneiform rays. In conclusion, non-weight-bearing X-rays had poor diagnostic accuracy for subtle Lisfranc injuries and their subtypes. CT was superior to X-rays and MRI in diagnosing first-ray injuries. Although not significantly different from CT in terms of overall diagnosis, MRI was superior to X-ray and CT in diagnosing second and cuneiform-ray injuries.

Effects of rigid and kinesio taping on plantar pressure distribution in patients with Lisfranc fracture sequelae

BACKGROUND

Patients with Lisfranc fractures may regain functional status after anatomical fixation, but they may experience sequelae such as flatfoot deformity and pain associated with foot pressure distribution during weight-bearing.

RESEARCH QUESTION

What is the impact of Lisfranc fracture sequelae on both the injured and uninjured sides, and how does the antipronation taping affect plantar pressure distribution parameters?

METHODS

Twenty-six patients who underwent anatomical fixation for Lisfranc fracture, displaying pronation on the injured side based on the Foot Posture Index-6 test, as well as 15 healthy subjects, participated in this study. Plantar pressure distribution measurements were conducted during barefoot walking for the healthy subjects. In the patient group, measurements were taken under two antipronation taping conditions (kinesio and rigid taping), as well as during barefoot walking.

RESULTS

Participants who received anatomical fixation after Lisfranc fracture exhibited significant alterations in plantar pressure distribution parameters on both the injured and uninjured sides, as compared to the control group. After the application of Kinesio Taping to the injured side, there was no significant change observed in the plantar pressure distribution values (p > 0.05). The analysis of the rigid taping on the injured side revealed statistically worse values in peak pressure of the hindfoot (p = 0.027) and maximum force of the midfoot and toes (p = 0.005 and p = 0.013, respectively) compared to the injured barefoot condition.

SIGNIFICANCE

Lisfranc fracture sequelae affected plantar pressure distribution on both injured and uninjured sides. Anti-pronation taping (kinesio and rigit), commonly used for foot conditions, did not lead to foot pressure distribution becoming more similar to that of the control group.

Suture button fixation yields high levels of patient reported outcomes, return to sport, and stable fixation in isolated Lisfranc injuries: A systematic review

IMPORTANCE

Lisfranc injuries remain a significant, but often misdiagnosed, orthopaedic injury. Alongside the traditional methods of surgical fixation, including arthrodesis and open reduction and internal fixation with screws, suture button fixation is an emerging technique.

OBJECTIVES

The purpose of this study is to investigate the efficacy of suture button fixation for treatment of Lisfranc injuries through a systematic review.

EVIDENCE REVIEW

A comprehensive literature review was conducted according to the preferred reporting items for systematic reviews using PubMed, Embase, Web of Science, and Cochrane databases for original, English-language studies observing outcomes of Lisfranc injury until August 19, 2022. The clinical studies with evidence level I-IV and at least a 12 month follow-up after the index surgery were included if they examined quantifiable outcomes of Lisfranc injury treated with suture button. Articles were excluded if they included case reports, systematic reviews, comments, editorials, surveys, animal studies, or biomechanical/cadaveric studies. Variables extracted from text and figures include demographic information, return to sport measures, patient reported outcomes, and complications.

FINDINGS

Of the 10 studies included, there were 186 total patients with an age range of 13-72. In every study, all patients were able to return to sport or activity with a return time averaging from 10.8 to 25.9 weeks. Postoperative American Orthopaedic Foot and Ankle Society scores ranged from 83.5 to 97.0 while pain Visual Analogue Scale ranged from 0.6 to 2.5. Complications were reported in four studies at a rate of 7.7% including two cases of diastasis, two cases of paraesthesia, one case of button irritation, and one of postoperative degenerative joint disease, with no reported revisions.

CONCLUSIONS AND RELEVANCE

In our systematic review, suture button fixation shows high levels of patient reported outcomes, return to sport, and stable fixation in isolated Lisfranc injuries. This surgical technique provides a physiologic reduction across the Lisfranc joint and reduces the need for reoperation including removal of hardware. However, further evidence such as large sample size high-quality randomized controlled trials is needed to draw a definitive conclusion regarding the best treatment for Lisfranc injuries.

LEVEL OF EVIDENCE

Level IV, Systematic Review of Level III and IV studies.

Suspensory Device Fixation of Lisfranc Injuries in a Southeast Asian Urban Population: Patient-Reported Functional Outcomes

Introduction Open reduction internal fixation (ORIF) and primary arthrodesis are two conventional options for the treatment of Lisfranc injuries. However, they are associated with implant-related complications. An alternative suspensory device construct using interosseous nonabsorbable sutures with endobuttons has been described with satisfactory results. This study aims to explore functional outcomes after suture button fixation of Lisfranc injuries in a Southeast Asian population. Methods This was a single-surgeon retrospective study of patients with Lisfranc injuries treated surgically using a suture button fixation technique between 2017 and 2019. Data collected included demographic information, pre-injury levels of activity, nature of injury, and type of surgery performed. The minimum postoperative follow-up was one year. The Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) were used to evaluate patient-reported outcomes. Scores were reported in percentage (%) with median and interquartile range. Results Twenty-nine patients with a mean age of 29 years (21-76) were recruited. Sixteen underwent suture button fixation only (SB), and 13 underwent suture button fixation with intercuneiform screw fixation and plating (SBM). The median scores for the FAOS and FAAM questionnaires were at least 80% in all domains. Twenty-eight patients (97%) were able to return to pre-injury activity level, 27 patients (93%) were able to return to sports. Only one patient was not satisfied with the outcomes of surgery. No patients had post-traumatic arthritis or hardware failure necessitating implant removal at the final follow-up. Conclusion This study has demonstrated that treatment of Lisfranc injuries with a suspensory device construct resulted in good outcomes with 97% of patients being able to return to pre-injury activity levels, and 93% of patients being able to return to sports. It may not be necessary to perform primary arthrodesis in uncomplicated Lisfranc injuries. This technique is also advantageous as implant removal is not routinely required due to the design and biomechanical properties of suspensory devices.

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.

Morphology of the Lisfranc Joint Complex

Lisfranc injuries are complicated injuries of the tarsometatarsal joint with high rates of sequelae. Both anatomy and injury of the Lisfranc joint are variably documented. Descriptions of these injuries and their associated structures vary greatly. The most injured structures are those of the Lisfranc joint complex, which involves the medial cuneiform, second and third metatarsals, and the dorsal, interosseous, and plantar Lisfranc ligaments. This study sought to examine morphology of the Lisfranc joint in cadavers. Twenty-two embalmed cadaveric feet were dissected (13 male, 9 female, 80.3 years ± 14.03) to isolate the bones and ligaments of the Lisfranc joint complex. The dorsal, interosseous, and plantar Lisfranc ligaments were present in each specimen. Each ligament was measured and morphology noted. The dissected dorsal Lisfranc ligament had consistent morphology (mean = 10.8 mm ± 1.79). The interosseous Lisfranc ligament had a consistent path, but 11/17 of specimens possessed a connection to the plantar Lisfranc ligament. The plantar Lisfranc ligament demonstrated wide variability with a Y-variant (n = 3) and a fan-shaped variant (n = 14). Ligament thickness was greatest in the interosseous Lisfranc ligament (mean = 13.74 ± 3.08) and least in the dorsal Lisfranc ligament (mean = 1.36 ± 0.42). While the objective of defining joint and ligament morphology was achieved, further questions were raised. Variations of the interosseous and plantar Lisfranc ligament may play a role in susceptibility to joint injury, and arthritic changes to the joints examined raise questions regarding the prevalence of arthritis in the uninjured Lisfranc joint.

Plantar Subluxation of First Metatarsal with Intercuneiform Dislocation: A Case Report of a New Type of Lisfranc Injury

Lisfranc injuries result when the bones or ligaments that support the midfoot are torn, and the classifications of these injuries are based on the coronal displacement of the metatarsals. On the saggital plane, the first metatarsal is usually dorsally dislocated due to dorsal ligament weakness. We present a case report of a 29-year-old woman who sustained a Lisfranc injury of her right foot with plantar subluxation of the first metatarsal, which was treated with open reduction and internal fixation of the first metatarsal and fusion of the second metatarsal.

A Rare Case of a Lisfranc Ligament Transection

Ligamentous Lisfranc injuries, which mimic a surgical transection are rare. Left untreated or missed, these injuries may result in severe complications including long-term disability. The present case describes a unique mechanism of injury via a sharp object puncture through the plantar surface of the midfoot. It highlights the utility of planning staged procedures to remove a large foreign body object, reports notable intraoperative techniques, and provides a decision management guide for treating this type of injury. Extensive surgical planning may be required when encountering similar cases and knowledge of this may be useful to providers.

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.

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.

Lisfranc injuries with dislocation the first tarsometatarsal joint: primary arthrodesis or internal fixation (a randomized controlled trial)

BACKGROUND

Open reduction and internal fixation (ORIF) is a popular method for treatment of displaced Lisfranc injuries. However, even with anatomic reduction and solid internal fixation, treatment does not provide good outcomes in certain severe dislocations. The purpose of this study was to compare ORIF and primary arthrodesis (PA) of the first tarsometatarsal (TMT) joint for Lisfranc injuries with the first TMT joint dislocation.

METHODS

Seventy-eight Lisfranc injuries with first TMT joint dislocation were finally enrolled and analyzed in a prospective, randomized trial comparing ORIF and PA. They were 50 males and females with a mean age of 40.7 years and randomized to ORIF group and PA group. Outcome measures included radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, Foot and Ankle Ability Measure (FAAM) Sports subscale, visual analog scale (VAS), and the 36-Item Short Form Health Survey (SF-36). Complications and revision rate were also analyzed.

RESULTS

Forty patients were treated by ORIF, while PA group includes 38 cases. Patients were followed up for 37.8(range, 24-48) months. At final follow-up, the mean AOFAS midfoot score (P < 0.01), the FAAM Sports subscale (P < 0.01), the physical function score (P < 0.05), and the Bodily Pain score of SF-36 (P < 0.05) after ORIF treatment were significantly lower than PA group. The mean VAS score in ORIF group was higher (P < 0.01). In ORIF group, redislocation of the first TMT joint was observed in ten cases, and thirteen patients had pain in midfoot. No redislocation and no hardware failure were identified in PA group.

CONCLUSION

PA of the first TMT joint provided a better medium-term outcome than ORIF for Lisfranc injuries with the first TMT dislocation. Possible complications and revision could be avoided by PA for dislocated first ray injuries.

Shortening the Return-to-Play Times in Elite Athletes With Unstable Isolated Lisfranc Ligament Injuries Using a Knotless Interosseous Suture Button: Case Series and Literature Review

Background:

Isolated unstable Lisfranc ligament injuries in elite athletes are associated with a lengthy period of rehabilitation and prolonged absence from competition.

Purpose:

To assess the efficacy of a knotless, interosseous suture button system for repairing isolated unstable ligamentous Lisfranc injuries and its capacity to allow accelerated rehabilitation with earlier weightbearing and return-to-play times in elite athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

The authors retrospectively reviewed data from a prospectively compiled database for elite athletes treated by a single surgeon. All included patients had clinical and magnetic resonance imaging evidence of an unstable isolated complete ligamentous Lisfranc injury requiring surgical reduction and stabilization. All patients underwent surgery using a knotless interosseous suture button to achieve stabilization, followed by a standardized postoperative regimen involving full weightbearing at 4 weeks, and all had a minimum postoperative follow-up of 2 years.

Results:

Included were 12 patients: 7 National Rugby League (NRL) players, 2 professional dancers, 1 Olympic gymnast, 1 professional wakeboarder, and 1 professional NRL referee. The mean age of the patients was 21.1 years (range, 16-34 years). Ten patients underwent acute surgical stabilization within 3 weeks of the injury, and 2 patients sustained chronic isolated Lisfranc instability that was initially treated nonoperatively. All athletes were able to return to full weightbearing by 4 weeks postoperatively, successfully returned to training by 9 to 12 weeks, and returned to full competition by 12 to 16 weeks. No major complications were reported.

Conclusion:

Knotless interosseous suture button stabilization was a reliable treatment option for both acute and chronic isolated ligamentous Lisfranc injuries in these elite athletes. This technique does not require hardware removal, allows early weightbearing with accelerated rehabilitation, and may shorten the return-to-play interval.

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.

Acute foot and ankle injuries and time return to sport

Foot and ankle sports injuries encompass a wide spectrum of conditions from simple contusions or sprains that resolve within days to more severe injuries that change the trajectory of an athlete’s sporting career. If missed, severe injuries could lead to prolonged absence from the sport and therefore a catastrophic impact on future performance. In this article, we discuss the presentation of the commonest foot and ankle sports injuries and share recent evidence to support an accurate diagnosis and best management practice.

Case Study: The Conservative Management of a Complex Mid Foot Injury in an Elite Professional Footballer

Lisfranc injuries, often accompanied with tarsometatarsal joint (TMTJ) disruption, are not well documented in football despite becoming increasingly more prevalent within other athletic populations. Currently there is a paucity of evidence documenting prognosis, rehabilitation strategy and outcome. The presented case summarizes the conservative rehabilitation and return to play of a 26-year-old elite professional footballer who presented with a Lisfranc injury alongside a 3^rd TMTJ coalition stress response. Injury was sustained when landing awkwardly from a jump causing the midfoot to be forced into a hyper-plantarflexed position. Palpation identified tenderness over the 2^nd and 3^rd MT, with a positive piano key test. Magnetic resonance imaging (MRI), computed tomography (CT), stork view x-ray and review from a leading foot and ankle specialist confirmed diagnosis, post-contradictory MRI results. Presented is a summary of the assessment process, conservative management of the injury and the resultant rehabilitation process followed, which led to the successful return to play of the athlete.

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.

Updates on Lisfranc Complex Injuries

Lisfranc injuries are a disruption of one or more of the tarsometatarsal joints and have an estimated incidence of 1/55 000 people. However, the total number of Lisfranc injuries could be underreported, because almost 20% of these injuries are initially missed. Because of the relative infrequency of these injuries, the current literature is inconsistent in regard to proper treatment. This article provides a review of Lisfranc complex injuries including relevant anatomy, diagnosis, treatment, classifications, operative approaches, and outcomes and complications. Based on existing evidence, it also proposes an algorithm the authors prefer for the evaluation and treatment of Lisfranc complex injuries.

Optimizing Return to Play for Common and Controversial Foot and Ankle Sports Injuries

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Surgical decision-making should consider factors to help optimize return to play for athletes with foot and ankle injuries, including injuries to the syndesmosis, the Achilles tendon, the fifth metatarsal, and the Lisfranc complex. Understanding influential factors on return to play may help orthopaedic surgeons counsel athletes and coaches on expectations for a timeline to return to play and performance metrics.

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Outcomes after rigid and flexible fixation for syndesmotic injuries are generally favorable. Some data support an earlier return to sport and higher functional scores with flexible fixation, in addition to lower rates of reoperation and a decreased incidence of malreduction, particularly with deltoid repair, if indicated.

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Minimally invasive techniques for Achilles tendon repair have been shown to have a decreased risk of wound complications. Athletes undergoing Achilles repair should expect to miss a full season of play to recover.

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Athletes with fifth metatarsal fractures have better return-to-play outcomes with surgical management and can expect a high return-to-play rate within approximately 3 months of surgery.

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Percutaneous treatment of Lisfranc injuries may expedite return to play relative to open procedures.

Adequate return to sports and sports activities after treatment of Lisfranc injury: a meta-analysis

IMPORTANCE

Although a large number of Lisfranc injuries occur during sports, data on sports outcomes, such as return to sport (RTS) rates and times as well as level of sports activities after treatment of this injury remain limited.

OBJECTIVE

The aim is to assess the RTS rates, times and the sports activity levels after different treatments of Lisfranc injuries.

EVIDENCE REVIEW

The electronic databases PubMed (MEDLINE), EMBASE, CDSR, DARE and CENTRAL were searched to identify relevant articles from January 1985 to July 2020. The mean RTS rates (to any level and preinjury level of sports) and times were extracted per study, and pooled wherever methodologically possible. Methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies criteria (MINORS).

FINDINGS

Fifteen studies were included in this review. Methodological quality of the studies was poor. The treatments reported in the studies were conservative treatment, surgical fixation and primary partial arthrodesis. For conservative treatment, the RTS rate regardless of sports level was 93% (95% CI 81% to 98%; n=42) and for return to preinjury level of sports was 88% (95% CI 75% to 95%; n=42). The fixation group showed a RTS percentage of 94% (95% CI 91% to 97%; n=270) to each level of sports and for return to the level before injury was 86% (95% CI 80% to 90%; n=188). In the primary partial arthrodesis group, the return to any level of sports was 94% (95% CI 85% to 98%; n=65) and for return to preinjury level was 74% (95% CI 62% to 83%; n=65). Mean time to RTS ranged from 7 to 33 weeks across all treatment groups. No data pooling was possible for this outcome measure. From the different studies, a total of 43 different sports and 440 physical activities were reported before treatment. After treatment, patients participated in 37 different sports (88%) and 391 different physical activities (89%).

CONCLUSIONS AND RELEVANCE

The different treatment options for Lisfranc injuries allow for good sport-specific outcomes with 93% to 94% of athletes returning to any level of sports, and 74% to 88% of athletes returning to their preinjury level of sport. These sport-specific outcomes can be used to inform patients about their expected sport-specific outcomes after different treatments of Lisfranc injuries.

LEVEL OF EVIDENCE

Systematic review and meta-analysis.

Change in the First Cuneiform-Second Metatarsal Distance After Simulated Ligamentous Lisfranc Injury Evaluated by Weightbearing CT Scans

BACKGROUND

This study aimed to investigate the widening between the first cuneiform (C1) and second metatarsal (M2) in a Lisfranc ligamentous complex (LLC) joint injury model subjected to successive ligament dissections evaluated by weightbearing computed tomography (CT) scans.

METHODS

Twenty-four intact cadaveric feet served as the control (condition 1). Each component of the LLC (dorsal, interosseous, and plantar ligaments-conditions 2, 3, and 4, respectively) were then sequentially dissected. The specimens were equally randomized to 1 of 3 additional dissections (first or second tarsometatarsal [TMT] joint capsule or first-second intercuneiform ligament [ICL]-conditions 5a, 5b, and 5c, respectively). One additional ligament was then randomly transected (eg, condition 6ac-transection of the first TMT capsule and ICL). Finally, the remaining ligament was transected (condition 7). After each dissection, CT scans were acquired under nonweightbearing (NWB, 0 kg), partial-weightbearing (PWB, 40 kg), and full-weightbearing (FWB, 80 kg) conditions. The distance between the lateral border of C1 and the medial border of M2 was assessed to evaluate diastasis. Linear regressions with 95% CIs and converted q values were used to compare the measured data.

RESULTS

No significant differences were found within the control. In condition 4, an average axial plane widening relative to control of 1.6 mm (95% CI, 1.5-1.8) and 2.1 mm (95% CI, 1.9-2.2) was observed under PWB and FWB. A coronal plane widening of 1.5 mm (95% CI, 1.3-1.6) and 1.9 mm (95% CI, 1.7-2.1) under PWB and FWB, respectively, was measured. A 95% CI of at least a 2-mm widening during PWB was demonstrated in 5c, 6ac, 6bc, and 7.

CONCLUSIONS

Weightbearing computed tomography (WBCT) scans were used to detect ligamentous Lisfranc injuries in a cadaveric model. Relative axial widening greater than 1.5 mm under PWB conditions could indicate a complete LLC injury. Complete transection of the intercuneiform 1-2 ligament was required to detect a 2-mm widening in the nonweightbearing condition.

CLINICAL RELEVANCE

This study provides insight on the detection of various severities of LLC injuries using WBCT imaging.

Morphological features of the lateral plantar ligament of the transverse metatarsal arch

The aim of this study was to elucidate the morphological characteristics of the lateral Lisfranc ligament in a large sample. This investigation examined 100 legs from 50 cadavers. Each of the lower limbs was dissected to identify the plantar aspect of the transverse metatarsal arch, and morphological characteristics of the lateral plantar ligament were assessed, including the length, width, and thickness of the fiber bundles. The majority of plantar ligaments originated from the base of M5 and the plantar aspect of the lateral cuneiform (LC). The lateral plantar ligament could be classified into three types: Type I, a band-like fiber bundle originating from the base of M5 to the LC (41%); Type II, originating from the base of M5 and the plantar aspect of LC and mostly connected the blending the fiber bundles of the tibialis posterior (TP) and long plantar ligament (LPL) (21%); and Type III, with no ligaments originating from the base of M5 and plantar aspect of the LC (38%). The morphological characteristics of Type I lateral plantar ligament were as follows: length, 31.8 ± 3.7 mm; width, 2.3 ± 1.0 mm; and thickness, 0.2 ± 0.3 mm. The morphology of the lateral plantar ligament showed variation, originating from the base of M5 and the plantar aspect of LC most commonly, but this was not the case in 38% of limbs. The findings suggest that the lateral plantar ligament might play a role in the transverse tarsal arch, indicating a cooperative mechanism with the TP and LPL.

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.

Morphological characteristics of the Lisfranc ligament

BACKGROUND

This study aimed to clarify the morphological characteristics of the Lisfranc ligament and the cuneiform 1-metatarsal 2&3 plantar ligament (CMPL).

METHODS

Forty legs from 20 cadavers were examined. Classification proceeded according to the number of fiber bundles in the Lisfranc ligament and the CMPL. Morphological features measured were fiber bundle length, width, thickness, and angle.

RESULTS

In Type I-a, the Lisfranc ligament and the CMPL were a single fiber bundle; in Type I-b, the Lisfranc ligament was a single fiber bundle, and the CMPL was two fiber bundles; in Type II-a, the Lisfranc ligament was a two fiber bundle, and the CMPL was a single fiber bundle; in Type II-b, the Lisfranc ligament and the CMPL were two fiber bundles; in Type III-a, the Lisfranc ligament was three fiber bundles, and the CMPL was a single fiber bundle; in Type III-b, the Lisfranc ligament was three fiber bundles, and the CMPL was two fiber bundles; in Type IV, the Lisfranc ligament and the CMPL could not be separated. Type I-a was seen in 37.5%, Type I-b in 10%, Type II-a in 30%, Type II-b in 7.5%, Type III-a in 7.5%, Type III-b in 2.5%, and Type IV in 5%. The Lisfranc ligament was significantly larger than the CMPL in total fiber bundle width, total fiber bundle thickness, and total fiber bundle angle.

CONCLUSION

The Lisfranc ligament had up to 3 fiber bundles and the CMPL had one or two fiber bundles; classifications were four types and two subgroups.

Comparison of primary arthrodesis versus open reduction with internal fixation for Lisfranc injuries: Systematic review and meta-analysis

Objective

Multiple studies have compared primary arthrodesis versus open reduction with internal fixation (ORIF) for surgical treatment of fractures of the Lisfranc joint, but their results have been inconsistent. Therefore, the present systematic review and meta-analysis was performed to compare the clinical efficacy of arthrodesis versus ORIF for the treatment of Lisfranc injuries.

Methods

Through searching the Embase, PubMed, PMC, CINAHL, PQDT, and Cochrane Library databases (from July 1998 to July 2018), we identified five case-controlled trials and two randomized controlled trials that compared the clinical efficacy of primary arthrodesis and ORIF for treating Lisfranc injuries. The extracted data were analyzed using Review manager 5.3 software.

Results

Through comparisons of data for primary arthrodesis and ORIF groups, we found no significant differences in the anatomic reduction rate, revision surgery rate, and total rate of complications between the different treatment approaches. However, arthrodesis was associated with a significantly better American Orthopedic Foot and Ankle Society (AOFAS) score, return to duty rate, and visual analog scale score with a lower incidence of hardware removal compared with ORIF.

Conclusions

For the treatment for Lisfranc injuries, primary arthrodesis was superior to ORIF based on a higher AOFAS score, better return to duty rate, lower postoperative pain, and lower requirement for internal fixation removal. Further evidence from future randomized controlled trials with higher quality and larger sample sizes is needed to confirm these findings.

Ultrasound as a Diagnostic Tool in the Assessment of Lisfranc Joint Injuries

OBJECTIVES

Ligamentous Lisfranc injuries are frequently overlooked because of subtle clinical presentations and diagnostic difficulties. The dorsal Lisfranc ligament (DLL) is easily visualized with ultrasound (US), which can provide quick, cost-effective diagnoses of disorders but is not considered standard clinical practice. This study sought to compare DLL measurement accuracy between US and cadaveric dissection.

METHODS

Ultrasound images of 22 embalmed cadaveric feet were obtained with an M-Turbo US machine and a 6-13-MHz linear array (FUJIFILM SonoSite, Inc, Bothell, WA). Images were measured in the US unit and again with ImageJ software (National Institutes of Health, Bethesda, MD). Specimens were dissected, and DLL morphologic characteristics were recorded.

RESULTS

Twenty-two specimens were scanned, however 4 were excluded, leaving a sample of 11 male and 7 female cadaveric specimens (mean age ± SD, 80.3 ± 14.03 years). The DLL length differences between SonoSite (8.39 ± 1.27 mm) and ImageJ (8.25 ± 1.84 mm) were not significant (P > .05). Both US DLL measurements significantly differed from the gross dissection measurement (10.8 ± 1.85 mm; P < .001). The morphologic characteristics of the DLL at dissection were consistent. Overall, 70% to 80% of the ligament length was represented by US compared to dissection. The dorsal joint space did not differ significantly between SonoSite (2.19 ± 0.49 mm) and ImageJ (2.05 ± 0.52; P > .05). Both US measurements were also significantly larger than dissection measurements (1.04 ± 0.24; P < .001). Intraclass correlation coefficients indicated good reliability for the DLL length (0.835) and moderate reliability for the dorsal joint space (0.714).

CONCLUSIONS

The DLL is underrepresented but easily distinguished by US, demonstrating its utility in Lisfranc injury diagnosis. Thus, we propose a 4-component assessment involving US, which may provide more rapid, cost-effective diagnoses of subtle Lisfranc injuries.

Biomechanical Evaluation With a Novel Cadaveric Model Using Supination and Pronation Testing of a Lisfranc Ligament Injury

Background:

Lisfranc joint injuries can be due to direct or indirect trauma and while the precise mechanisms are unknown, twisting or axial force through the foot is a suspected contributor. Cadaveric models are a useful way to evaluate injury patterns and models of fixation, but a frequent limitation is the amount of joint displacement after injury. The purpose of this study was to test a cadaveric model that includes axial load, foot plantarflexion and pronation-supination motion, which could re-create bone diastasis similar to what is seen in subtle Lisfranc injuries. Our hypothesis was that applying pronation and supination motion to a cadaveric model would produce reliable and measurable bone displacements.

Methods:

Twenty-four fresh-frozen lower leg cadaveric specimens were used. The medial (C1) and intermediate (C2) cuneiforms and the first (M1) and second (M2) metatarsal bones were marked. A complete ligament injury was performed between C1-C2 and C1-M2 in 12 specimens (group 1), and between C1-C2, C1-M2, C1-M1, and C2-M2 in 12 matched specimens (group 2). Foot pronation and supination in addition to an axial load of 400 N was applied to the specimens. A 3D digitizer was used to measure bone distances.

Results:

After ligament injury, distances changed as follows: C1-C2 increased 3 mm (23%) with supination; C1-M2 increased 4 mm (21%) with pronation (no differences between groups). As expected, distances between C1-M1 and C2-M2 only changed in group 2, increasing 3 mm (14%) and 2 mm (16%), respectively (no differences between pronation and supination). M1-M2 and C2-M1 distances did not reach significant difference for any condition.

Conclusions:

Pronation or supination in addition to axial load produced measurable bone displacements in a cadaveric model of Lisfranc injury using sectioned ligaments. Distances M1-M2 and C2-M1 were not reliable to detect injury in this model.

Clinical Relevance:

This new cadaveric Lisfranc model included foot pronation-supination in addition to axial load delivering measurable bone diastasis. It was a reliable Lisfranc cadaveric model that could be used to test different Lisfranc reconstructions.

Primary arthrodesis versus open reduction internal fixation for complete Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes

BACKGROUND

The aims of this retrospective study were to compare the functional and radiological outcomes of primary arthrodesis and open reduction internal fixation (ORIF) for the treatment of complete Lisfranc fracture dislocations.

METHODS

A retrospective cohort study of 39 patients treated for a complete Lisfranc fracture dislocation, defined as Myerson types A and C2, over a period of 8 years at a level 1 trauma centre was performed. Of these, 18 underwent primary arthrodesis, and 21 ORIF. The primary outcome measures included the American Orthopaedic Foot and Ankle Society score, the validated Manchester Oxford Foot Questionnaire functional tool, and the secondary outcome was the radiological Wilppula classification of anatomical reduction.

RESULTS

Significantly better functional outcomes were seen in the primary arthrodesis group. These patients had a mean Manchester Oxford Foot Questionnaire score of 30.1 points, compared with 45.1 for the ORIF group (P = 0.017). Similarly, the mean American Orthopaedic Foot and Ankle Society score was 71.8 points in the fusion group versus 62.5 in the ORIF group (P = 0.14). Functional outcome was dependent on the quality of final reduction (P < 0.001). Primary arthrodesis achieved good initial reduction in 83% cases compared to 62% with ORIF (P = 0.138). There was a loss of reduction quality of 47% in the ORIF group over time.

CONCLUSION

Primary arthrodesis for complete Lisfranc fracture dislocations resulted in improved functional outcomes and quality of reduction compared to open reduction and internal fixation.

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.

Injury Pattern in Ligamentous Lisfranc Injuries in Competitive Athletes

BACKGROUND:

We report data on the largest cohort to date of patients who sustained a ligamentous Lisfranc injury during sport. To date, the prevalence of concurrent intercuneiform ligament injuries in the competitive athlete with subtle Lisfranc instability has not been reported.

METHODS:

Eighty-two patients (64 males, 18 females) sustained an unstable Lisfranc injury (49 left, 33 right) and met inclusion criteria. Injuries were classified as traditional dislocation (TRAD, first to second TMT ligament tear), medial column dislocation (MCD, second TMT, and medial-middle cuneiform ligament tear), or proximal extension dislocation (PE, first, second, and medial-middle cuneiform ligament tear) and the injury pattern confirmed at surgery. All athletes underwent open reduction with internal fixation (ORIF) of each unstable midfoot segment. Fisher exact tests and 2-tailed t tests were used to analyze statistical significance according to injury pattern, sport, gender difference, hindfoot angle alignment, and injured side ( P < .05).

RESULTS:

Average age of athletes was 21.0 ± 5.3 years old (range 12-40), and return to sports was 7.5 ± 2.1 months. Injury distribution was as follows: TRAD (n = 40), MCD (n = 17), and PE (n = 23). MCD trended toward a longer return to sport (8.4 ± 3.3 months, P = .074). Football was the most common sport at time of injury (n = 48). Wakeboard athletes (n = 5) were older (31.4 ± 3.2, P = .0002), and MCD tears were more prevalent among them ( P = .061). Basketball (n = 13) players were significantly younger (19.1 ± 2.5 years, P = .028) and returned to sports quicker (5.2 ± 0.7, P = .0002). Return to sport data indicated a typical population for athletes with Lisfranc injury in these sports.

CONCLUSION:

Proximal extension disruption (intercuneiform ligament tear) occurred in 50% of these low-energy Lisfranc athletic injuries. MCD and PE may be more prevalent than previously understood. This is the first study to document the extent, pattern, and prevalence of associated intercuneiform ligament tears in the competitive athlete with a low-energy subtle, unstable Lisfranc injury.

LEVEL OF EVIDENCE:

Level IV, retrospective case series.

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.

Performance-Based Outcomes Following Lisfranc Injury Among Professional American Football and Rugby Athletes

Professional National Football League (NFL) and rugby athletes have high rates of Lisfranc injuries. Although favorable return-to-play rates have been previously reported, a thorough assessment of postinjury performance is lacking. Professional NFL and rugby athletes who sustained a Lisfranc injury were identified using a well-established protocol confirmed by multiple sources of the public record. Return-to-play rate and time to return were determined for each athlete. League participation and game performance were collected 1 season prior to injury and up to 3 seasons after injury. Statistical analysis was performed, with P≤.05 being significant. A total of 47 athletes (NFL=35, rugby=12) with Lisfranc injuries were identified, having 23 ligamentous injuries and 24 fractures. Thirty-five (75%) were treated operatively. Among NFL players, 29 (83%) returned to play, taking 10.0±2.9 months to do so. Overall, NFL players started fewer games 2 and 3 seasons following surgery (P=.002 and .035, respectively) and showed a significant decline in performance 1 season after return compared with preinjury levels (21%; P=.05). Offensive players had a significantly greater decline in statistical performance compared with defensive counterparts (P=.02). Although professional NFL athletes return to play at a high rate (83%) following Lisfranc injury, their league participation and performance is significantly decreased on return. Ligamentous and bony injuries have similar prognoses; however, offensive players show greater declines in performance compared with defensive players. To best guide therapy, players, coaches, and team physicians should be aware of the impact of Lisfranc injuries on career performance and longevity. [Orthopedics. 2018; 41(4):e479-e482.].

Dorsal bridge plating or transarticular screws for Lisfranc fracture dislocations: a retrospective study comparing functional and radiological outcomes

Aims

The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.

Patients and Methods

A total of 108 patients were treated for a Lisfranc fracture dislocation over a period of nine years. Of these, 38 underwent transarticular screw fixation, 45 dorsal bridge plating, and 25 a combination technique. Injuries were assessed preoperatively according to the Myerson classification system. The outcome measures included the American Orthopaedic Foot and Ankle Society (AOFAS) score, the validated Manchester Oxford Foot Questionnaire (MOXFQ) functional tool, and the radiological Wilppula classification of anatomical reduction.

Results

Significantly better functional outcomes were seen in the bridge plate group. These patients had a mean AOFAS score of 82.5 points, compared with 71.0 for the screw group and 63.3 for the combination group (p < 0.001). Similarly, the mean Manchester Oxford Foot Questionnaire score was 25.6 points in the bridge plate group, 38.1 in the screw group, and 45.5 in the combination group (p < 0.001). Functional outcome was dependent on the quality of reduction (p < 0.001). A trend was noted which indicated that plate fixation is associated with a better anatomical reduction (p = 0.06). Myerson types A and C2 significantly predicted a poorer functional outcome, suggesting that total incongruity in either a homolateral or divergent pattern leads to worse outcomes. The greater the number of columns fixed the worse the outcome (p < 0.001).

Conclusion

Patients treated with dorsal bridge plating have better functional and radiological outcomes than those treated with transarticular screws or a combination technique. Cite this article: Bone Joint J 2018;100-B:468-74.

Foot and Ankle Surgery: Common Problems and Solutions

Participation in sports activity has increased significantly during the last several decades. This phenomenon has exposed orthopedic sports medicine surgeons to new challenges regarding the diagnosis and management of common sport-related injuries. Arthroscopy is becoming more commonly used in many of the surgical procedures for these injuries and carries the risk of complications. Wound and nerve complications make up the bulk of complications in most procedures. This article describes these complications associated with the common surgical procedures related to foot and ankle sport-related injuries and how to address and prevent them.

Injury Characteristics of Low-Energy Lisfranc Injuries Compared With High-Energy Injuries

BACKGROUND

Lisfranc injuries result from high- and low-energy mechanisms though the literature has been more focused on high-energy mechanisms. A comparison of high-energy (HE) and low-energy (LE) injury patterns is lacking. The objective of this study was to report injury patterns in LE Lisfranc joint injuries and compare them to HE injury patterns.

METHODS

Operative Lisfranc injuries were identified over a 5-year period. Patient demographics, mechanism of injury, injury pattern, associated injuries, missed diagnoses, clinical course, and imaging studies were reviewed and compared. HE mechanism was defined as motor vehicle crash, motorcycle crash, direct crush, and fall from greater than 4 feet and LE mechanism as athletic activity, ground level twisting, or fall from less than 4 feet. Thirty-two HE and 48 LE cases were identified with 19.3 months of average follow-up.

RESULTS

There were no differences in demographics or missed diagnosis frequency (21% HE vs 18% LE). Time to seek care was not significantly different. HE injuries were more likely to have concomitant nonfoot fractures (37% vs 6%), concomitant foot fractures (78% vs 4%), cuboid fractures (31% vs 6%), metatarsal base fractures (84% vs 29%), displaced intra-articular fractures (59% vs 4%), and involvement of all 5 rays (23% vs 6%). LE injuries were more commonly ligamentous (68% vs 16%), with fewer rays involved (2.7 vs 4.1).

CONCLUSIONS

LE mechanisms were a more common cause of Lisfranc joint injury in this cohort. These mechanisms generally resulted in an isolated, primarily ligamentous injury sparing the lateral column. Both types had high rates of missed injury that could result in delayed treatment. Differences in injury patterns could help direct future research to optimize treatment algorithms.

LEVEL OF EVIDENCE

Level III, comparative series.