The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study

Lisfranc Injury: Recent Trends in Management

Lisfranc injury refers to a group of bony or ligamentous injuries in which one or more of the metatarsals are displaced with respect to the tarsus. These injuries can occur as a result of either high-energy trauma like motor vehicle accidents and falls from height, or low-energy trauma from sports activities. A significant proportion of Lisfranc injuries are missed initially. The effects of delayed and missed diagnosed cases can be devastating as patients may develop progressive midfoot instability, collapse of arch, abduction of forefoot, and post-traumatic osteoarthritis, which can cause chronic pain, stiffness, and foot and ankle complex dysfunction. Favourable outcomes are associated with early diagnosis and prompt treatment. Open reduction and internal fixation (ORIF) with arthrodesis has better results than ORIF alone in functional outcomes. Dorsal bridge plates are currently the preferred mode of fixation due to advantages over trans-articular screws.

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.

Effect of different fusion types on kinematics of midfoot lateral column: a comparative biomechanical study

Background

This study aimed to compare the biomechanical outcomes of the isolated 4^th or 5^th tarsometatarsal (TMT) joint arthrodesis with the whole lateral TMT joints arthrodesis.

Methods

Ten cadaveric lower legs underwent isolated 4^th TMT joint arthrodesis, 5^th TMT joint arthrodesis, and whole lateral TMT joints arthrodesis in sequence. Texson F-scan and K-scanTM joint sensor were used to test the medial and lateral plantar pressure and the pressure of calcaneocuboid joint.

Results

Compared with the intact foot, the lateral forefoot pressure increased significantly (P<0.05) after 4^th TMT joint fusion. The medial forefoot pressure was significantly lower in the 5^th TMT joint fusion than that in the intact foot (P<0.05) and the 4^th TMT joint fusion (P<0.05), but higher than that in the whole lateral TMT joints fusion (P<0.05). On the contrary, the lateral forefoot pressure was significantly higher in the 5^th TMT joint fusion than that in the intact foot and the 4^th TMT joint fusion, but lower than that in the whole lateral TMT joints fusion (P<0.05). The medial forefoot pressure was the lowest (P<0.05) and lateral forefoot pressure was the highest (P<0.05) in the whole lateral TMT joints fusion. The calcaneocuboid joint pressure increased respectively with the intact foot being the lowest, followed by the isolated 4^th TMT joint arthrodesis, the isolated 5^th TMT joint arthrodesis, and the whole lateral TMT joints arthrodesis (P<0.05).

Conclusions

The isolated 4^th or 5^th TMT joint arthrodesis has less impact on the pressure of forefoot and adjacent joints than the whole lateral TMT joints arthrodesis. The isolated 4^th TMT joint arthrodesis has the lowest influence on the pressure of forefoot and adjacent joints.

Glossary of terms for musculoskeletal radiology

Members of the International Skeletal Society compiled a glossary of terms for musculoskeletal radiology. The authors also represent national radiology or pathology societies in Asia, Australia, Europe, and the USA. We provide brief descriptions of musculoskeletal structures, disease processes, and syndromes and address their imaging features. Given the abundance of musculoskeletal disorders and derangements, we chose to omit most terms relating to neoplasm, spine, intervention, and pediatrics. Consensus agreement was obtained from 19 musculoskeletal radiology societies worldwide.

Lisfranc fracture-dislocations: current management

It is essential to know and understand the anatomy of the tarsometatarsal (TMT) joint (Lisfranc joint) to achieve a correct diagnosis and proper treatment of the injuries that occur at that level.

Up to 20% of Lisfranc fracture-dislocations go unnoticed or are diagnosed late, especially low-energy injuries or purely ligamentous injuries. Severe sequelae such as post-traumatic osteoarthritis and foot deformities can create serious disability.

We must be attentive to the clinical and radiological signs of an injury to the Lisfranc joint and expand the study with weight-bearing radiographs or computed tomography (CT) scans.

Only in stable lesions and in those without displacement is conservative treatment indicated, along with immobilisation and initial avoidance of weight-bearing.

Through surgical treatment we seek to achieve two objectives: optimal anatomical reduction, a factor that directly influences the results; and the stability of the first, second and third cuneiform-metatarsal joints.

There are three main controversies regarding the surgical treatment of Lisfranc injuries: osteosynthesis versus primary arthrodesis; transarticular screws versus dorsal plates; and the most appropriate surgical approach.

The surgical treatment we prefer is open reduction and internal fixation (ORIF) with transarticular screws or with dorsal plates in cases of comminution of metatarsals or cuneiform bones.

Cite this article: EFORT Open Rev 2019;4:430-444. DOI: 10.1302/2058-5241.4.180076

Cost comparison and complication rate of Lisfranc injuries treated with open reduction internal fixation versus primary arthrodesis

BACKGROUND

Controversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation (ORIF) or primary arthrodesis is superior remains unknown.

METHODS

A national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007 to 2016 based on international classification of diseases (ICD) codes (PearlDiver, Colorado Springs, CO). Patients with lisfranc injuries then progressed to either nonoperative treatment, ORIF, or primary arthrodesis. Associated treatment costs were determined along with complication rate and hardware removal rate.

RESULTS

2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent nonoperative management, 670 underwent ORIF, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5005.82) than for ORIF ($3961.97,P = 0.045). The overall complication rate was 23.1% (155/670) for ORIF and 30.2% (64/212) for primary arthrodesis (P = 0.04). Rates of hardware removal were 43.6% (292/670) for ORIF and 18.4% (39/212) for arthrodesis (P < 0.001). Furthermore, 2.5% (17/670) patients in the ORIF group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12.

DISCUSSION

Primary arthrodesis is both significantly more expensive and has a higher complication rate than ORIF. Open reduction and internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with ORIF.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

Comparison of Screws to Plate-and-Screw Constructs for Midfoot Arthrodesis

BACKGROUND

We performed a prospective comparison of screws versus plate-and-screws for midfoot arthrodesis.

MATERIALS

Between 2010 and 2015, a total of 50 patients with midfoot arthritis received screws or plate-and-screws for their midfoot arthrodesis. Function and pain were graded with the Foot and Ankle Ability Measures (FAAM) and visual analog scale (VAS), respectively. Data regarding arthrodesis healing and complications were recorded.

RESULTS

Twenty-five patients received screws for fusion, where 21 achieved full arthrodesis healing by 6 months from surgery. Mean FAAM increased from 46.4 to 82.7 of 100 between initial and final visit. Mean pain decreased from 8.3 to 2.1 of 10 between initial and latest encounter. Twenty-five patients received plate-and-screws for their fusion, where 23 achieved full arthrodesis healing by 6 months from surgery. Mean FAAM increased from 48.2 to 86.3 of 100 between initial and final visit. Mean pain decreased from 8.0 to 1.8 of 10 between initial and latest encounter. These postoperative scores were not significantly different from patients with screws ( P > .05). Three and 6 patients with screws versus plate-and-screws, respectively, developed wound complications ( P = .03). Four and 2 patients with screws versus plate-and-screws, respectively, developed delayed or nonunion of their arthrodesis ( P = .15).

DISCUSSION

A comparison of outcomes of midfoot arthrodesis with screws or plate-and-screws has not been previously reported. Both constructs provide improved function and pain. Using screws might generate less wound complications, but using plate-and-screws might produce higher rates of bony healing.

LEVEL OF EVIDENCE

Level I, randomized, prospective, and comparative cohort 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.].

Tarsometatarsal joint communication during fluoroscopy-guided therapeutic joint injections and relationship with patient age and degree of osteoarthritis

OBJECTIVE

Although the tarsometatarsal joints are separated into three distinct synovial compartments, communications between adjacent compartments are often noted during image-guided injections. This study aims to determine whether abnormal inter-compartment tarsometatarsal joint communication is associated with patient age or degree of tarsometatarsal osteoarthritis.

MATERIALS AND METHODS

One hundred forty tarsometatarsal injections were retrospectively reviewed by two radiologists. Extent of inter-compartment communication and degree of osteoarthritis were independently scored. Univariate and multivariable analyses were performed to assess whether the presence of and number of abnormal joint communications were related to age and degree of osteoarthritis.

RESULTS

Forty out of 140 tarsometatarsal joints showed abnormal communication with a separate synovial compartment, and 3 of the 40 showed abnormal communication with two separate compartments. On univariate analysis, higher grade osteoarthritis (p < 0.001) and older age (p = 0.014) were associated with an increased likelihood of abnormal inter-compartment tarsometatarsal communication and a greater number of these abnormal communications. On multivariate analysis, the degree of osteoarthritis remained a significant predictor of the presence of (p < 0.001) and number of (p < 0.001) abnormal communications, while the association of age was not statistically significant. There was significant correlation between age and degree of osteoarthritis (p < 0.001).

CONCLUSION

Higher grade osteoarthritis increases the likelihood of abnormal inter-compartment tarsometatarsal joint communication and is associated with a greater number of abnormal communications. Diagnostic injection to localize a symptomatic tarsometatarsal joint may be less reliable in the setting of advanced osteoarthritis.

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.

Is Pes Cavus Alignment Associated With Lisfranc Injuries of the Foot?

BACKGROUND

Lisfranc (tarsometatarsal joint) injuries are relatively rare, accounting for less than 1% of all fractures, and as many as 20% of subtle Lisfranc injuries are missed at the initial patient presentation. An undiagnosed Lisfranc injury can have devastating consequences to the patient. Therefore, any factor that can raise a clinician's index of suspicion to make this diagnosis is potentially important. The cavus foot has been associated with various maladies of the lower extremity, but to our knowledge, it has not been reported to be associated with Lisfranc injury.

QUESTIONS/PURPOSES

Do patients who experience a low-energy Lisfranc injury have greater talar head coverage and a greater talo-first metatarsal angle than control subjects?

METHODS

A retrospective, case-control study was conducted from September 2011 to December 2014 to identify patients diagnosed and treated for a low-energy Lisfranc injury. Twenty-three adult patients with an average age of 42.6 years (SD, 16.3 years) were identified and compared with 61 adult control subjects with an average age of 49.4 years (SD, 14.1 years). Control subjects came from the practice of a fellowship-trained foot and ankle orthopaedic surgeon. Control subjects underwent a history and physical, clinical examination, and diagnostic imaging to confirm that they had no prior foot disorder, no prior foot surgeries, were within 3 years of age of a patient with a Lisfranc injury, and were independent ambulators. Two authors (DSD and JDP) measured the talonavicular and talo-first metatarsal angles on weightbearing AP and lateral radiographs of the foot. The intrarater reliability and interrater reliability for the talo-first metatarsal angle and the talonavicular angle showed high agreement. The intrarater intraclass correlation coefficients (ICC) of the talo-first metatarsal angle were 0.94 (95% CI, 0.91-0.96) and 0.93 (95% CI, 0.9-0.96). For the talonavicular angle the ICCs were 0.83 (95% CI, 0.75-0.89) and 0.88 (95% CI, 0.81-0.92) for Raters 1 and 2 respectively. The interrater ICCs were 0.91 (95% CI, 0.69-0.96) for the talo-first metatarsal angle and 0.9 (95% CI, 0.85-0.94) for the talonavicular angle. The patients and controls were compared to determine if the patients who sustained a Lisfranc injury were more likely to have a pes cavus foot alignment. We performed a mixed modeling analysis to control for potential cofounding variables and determine if there was an association of Lisfranc injury with the talo-first metatarsal angle and the talonavicular angle.

RESULTS

After controlling for confounding variables such as the effect of the measurement round effect and the effect of the rater, our repeated measures analysis via mixed model showed patients were associated with a higher talo-first metatarsal angle than control subjects (adjusted least square mean for patients = 3.05; for controls = -2.65; mean difference, 5.7; p = 0.001). Repeated measures analysis via mixed model showed that patients also were associated with a more positive talonavicular angle than control subjects (adjusted least square mean for patients = -4.83, for controls = -11; mean difference, 6.17; p = 0.002). Patients with Lisfranc injuries had a higher mean talo-first metatarsal angle than did control subjects (1.9° ± 7.9° versus -2.2° ± 7.3°; mean difference, 4.1°; 95% CI, -7.7° to -0.5°; p = 0.028), and less talar uncovering (-4.2° ± 9.7° versus -11° ± 8°; mean difference, 6.7°; 95% CI, -6.7° to -10.8°; p = 0.001).

CONCLUSIONS

We found that cavus midfoot alignment was more prevalent among patients with Lisfranc injuries than among individuals with no foot injury or disorder. Although this does not suggest that cavus alignment causes or predisposes patients to this injury, we believe the finding is important because this provides a radiographic parameter that clinicians can use to raise their index of suspicion for a Lisfranc injury and aggressively pursue this diagnosis. Future studies would benefit from obtaining contralateral foot imaging at the time of injury in all patients with Lisfranc injury or prospectively following patients with foot imaging and recording the incidence of future foot injury.

LEVEL OF EVIDENCE

Level III, prognostic study.

Gravity Stress Radiograph Revealing Instability at the First Metatarso-Cuneiform Joint in Lisfranc Injury

Lisfranc injuries are commonly missed in the acute setting, largely due to subtle findings that often require weightbearing radiographs or more complex imaging for diagnosis. The long-term consequences of missed injuries are debilitating osteoarthritis of the midfoot, but this may be prevented with appropriate diagnosis and treatment. This case study presents a Lisfranc injury initially diagnosed by gravity stress radiograph. While used for other injuries, there is no literature on the use of gravity stress radiographs for diagnosis of Lisfranc injuries. The use of this simple technique to accurately diagnose Lisfranc injuries may improve detection and patient outcomes.

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.

Combined Innovative Portal Arthroscopy and Fluoroscopy-Assisted Reduction and Fixation in Subtle Injury of the Lisfranc Joint Complex: Analysis of 10 Cases

Subtle injuries of the Lisfranc joint complex are uncommon and difficult to diagnose clinically and thus are easily missed even by experienced orthopedic doctors. Misdiagnosed injuries can lead to chronic disability until eventual fusion surgery. We describe 10 cases diagnosed with subtle injury of the Lisfranc joint that were treated with combined innovative portal arthroscopy and fluoroscopy-assisted reduction and percutaneous screw fixation in an interfragmentary fashion. The distance between the first and second metatarsals (the Lisfranc distance) and that between the medial cuneiform and fifth metatarsal base (foot arch height) was measured before and after surgery. The American Orthopaedic Foot and Ankle Society function score was evaluated perioperatively. The average preoperative and postoperative Lisfranc distance was 4.38 ± 0.39 mm and 2.68 ± 0.9 mm, the foot arch height was 12.63 ± 2.75 mm and 21.80 ± 3.50 mm, and the American Orthopaedic Foot and Ankle Society score was 59.1 ± 5.69 and 86.8 ± 10.1, respectively. Of the 10 patients, 3 had excellent outcomes, 6 had good outcomes, and 1 had a fair outcome. In conclusion, we report a useful and minimally invasive surgery for acute, subacute, and even chronic subtle injury of the Lisfranc joint. The Lisfranc distance, foot arch height, and function of the foot were restored clinically, and all measurements showed statistically significant differences.

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.

Anatomic Parameters of the Lisfranc Joint Complex in a Radiographic and Cadaveric Comparison

Subtle injuries to the Lisfranc joint complex are difficult to diagnose clinically and radiographically and can ultimately result in obvious disability if misdiagnosed. However, no previous study has shown the true mean average distance between the base of the first and second metatarsals (the Lisfranc distance). Therefore, in the present study, the anatomic and radiographic parameters of the Lisfranc joint were studied in detail to assist in the evaluation of Lisfranc injuries. The parameters of the Lisfranc joint complex in 100 normal volunteers and 10 cadavers were measured, including the medial, lateral depth of the mortise joint, width and height of the second metatarsal base, and distance between the base of the first and second metatarsals. The mean average Lisfranc distance was 0.24 ± 0.06 mm in the left foot and 0.25 ± 0.06 mm in the right foot for the radiographic group (p = .089) and 0.39 ± 0.04 mm in the left foot and 0.37 ± 0.04 mm in the right foot for the cadaver group (p = .129). The medial depth and Lisfranc distance in the radiographic group were smaller than the same measurements in the cadaver group, and these differences were statistically significant (medial depth, p < .001; Lisfranc distance, p < .001). The lateral depth and second metatarsal height in the radiographic group were larger than the same measurements in the cadaver group, and these differences were statistically significant (lateral depth, p < .001; second metatarsal height, p < .001). The second metatarsal width was the same in the 2 groups (p = .651). In conclusion, if the Lisfranc distance is >3.0 mm radiographically, a subtle injury to the Lisfranc joint should be highly suspected. No test of stability was performed between shallow and narrow versus deeper and broader Lisfranc mortise configurations. We merely speculated that a deeper and wider mortise is likely to be more stable than one that is shallow and narrow, probably owing to the presence of broader ligaments.

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.

The injuries to the fourth and fifth tarsometatarsal joints: A review of the surgical management by internal fixation, arthrodesis and arthroplasty

The surgical management to the injuries of the fourth and fifth tarsometatarsal (TMT) joints is controversial. We briefly review the anatomical characteristics to the injuries, the diagnosis, as well as the individualized treatment of the injuries of the fourth and fifth TMT joints by open reduction and internal fixation, TMT arthrodesis and arthroplasty. We conclude that open reduction and internal fixation is the recommended option for acute injuries, while arthrodesis can be used in cases of malunion of the fourth and fifth TMT joints with gross pain or arthritic changes and obvious structural deformity. Arthroplasty is an effective salvage operation mainly used in high-demand patients with severe TMT arthritis. Finally, we propose a recommended treatment algorithm (based on the literature and our experience), taking into account the specific indications for internal fixation, TMT arthrodesis and arthroplasty to optimize the individualized treatment.

Data sources/Study selection Data from survey reports, descriptive, cross-sectional and longitudinal studies published from 2002 to 2012 on the topic of the injuries to the fourth and fifth tarsometatarsal joint on human and radiography studies were included.

Data Extraction The data was extracted from online resources of American Orthopaedic Foot & Ankle Society, American Academy of Orthopaedic Surgeons, US National Library of Medicine, The MEDLINE.

Conclusion It is important to comprehend the specific anatomical characteristics and grasp the strict indications, advantages and disadvantages of the ORIF, TMT arthrodesis and arthroplasty to optimize the individualized treatment of the fourth and fifth TMT joints injuries in a maximum extent.

One Month Old Neglected Lisfrancs Fracture Dislocation Treated with Wagner's External Fixator and Percutaneous Screw Fixation : A Case Report

Introduction:

Lisfrancs Fracture dislocation is not commonly seen and it often goes missed leading to numerous complications. We present a case of neglected Lisfrancs fracture dislocation who presented after 1 month and its management.

Case Report:

A 27-year-old man came with the complaints of pain and swelling of the right foot following a fall from a motorcycle 1 month back. On Radiographic evaluation it showed presence Lisfrancs fracture Dislocation with comminuted fracture of the proximal phalanx of the great toe and distal fibula fracture. Closed reduction was attempted initially which was unsuccessful and was followed by open reduction which also failed. Reduction was then achieved using Wagner’s external fixation distractor device and supplemented with percutaneously passed screws. The external fixator was continued for 3 weeks followed by below knee cast for 6 weeks. The patient regained normal gait and returned to work and his previous physical activity level without recurrent dislocation.

Conclusion:

This report highlights the necessity of prompt open reduction and the need of external fixation to achieve and maintain reduction in case of neglected cases. We advocate this approach to achieve reduction in neglected cases where open reduction is unsuccessful.

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: 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.

Ultrasound assessment of bilateral symmetry in dorsal Lisfranc ligament

Bilateral symmetry of the ligaments is a common assumption used as an intrasubject control for clinical diagnosis. The present study investigated the bilateral symmetry of the dorsal Lisfranc ligament (dLL) using ultrasound. Data were acquired from 50 asymptomatic subjects in a seated position at a loaded calf raise machine equipped with a force plate. The testing conditions included low, medium, and high stress at 0° and 15° abducted foot positions. Images of the dLL were captured and measured using a 10.0-MHz ultrasound transducer and custom written MATLAB software, respectively. The data were analyzed using paired t tests to compare the bilateral measurements of the dLL length under all test conditions. The bilateral pooled dLL length was 7.01 ± 1.38 mm and showed a moderate correlation with the foot length and width. No bilateral differences were found in the dLL length under any of the stress loads in the abducted position or under the medium and high stress load in the rectus position. However, the low stress load rectus position demonstrated a significant bilateral difference in the dLL length (p = .005). The smallest bilateral difference was observed at the 15° abducted position under medium stress (measurement error mean -0.062 mm). Our data suggest that the contralateral dLL length can be used as an intrasubject control for clinical purposes. However, we recommend that the dLL length measurements should be taken in weightbearing position with the foot in the abducted position under medium stress (bilateral stance), reducing potential strain-induced asymmetry.

Modified anteroposterior and oblique radiographs of the midfoot and their efficiency in demonstrating the tarsometatarsal joints

AIM

To assess whether conventional and modified anteroposterior and oblique radiographs of the midfoot can be used to demonstrate tarsometatarsal (TMT) joints clearly.

MATERIALS AND METHODS

Conventional anteroposterior and oblique radiographs of the midfoot were taken of 152 volunteers. Modified radiographs of the midfoot were taken of 14 volunteers by tilting the radiographic system tube and placing volunteers' feet on different footboards. Both conventional and modified radiographs were taken of 27 patients with midfoot injuries to demonstrate the injuries to the TMT joints. Two radiologists assessed the radiological demonstration of the TMT joints. Statistical analyses were performed using SPSS 13.0 for Windows.

RESULTS

Conventional radiographs of the midfoot did not sufficiently clearly demonstrate TMT joints. They could not demonstrate the majority of the TMT joints. The modified anteroposterior radiographs of the midfoot taken with the radiographic system tube tilted 30° towards the calcaneus demonstrated most TMT joints clearly. The modified oblique radiographs taken with the foot placed on a 30° footboard and with the radiographic system tube tilted 20° towards the calcaneus also showed the majority of TMT joints clearly. For the evaluation of midfoot injuries, modified radiographs perform better than conventional radiographs.

CONCLUSIONS

Modified anteroposterior and oblique radiographs, which allow clear detection of the articulation and trabeculae of TMT joints, are valuable alternatives when assessing TMT joints.

Tarsometatarsal/Lisfranc joint

Accurate early diagnosis with adequate reduction and maintenance of anatomic alignment of the dislocation or fracture within the Lisfranc joint complex have been found to be the key to successful outcomes regarding this injury. Because of the anatomic variations, the thin soft tissue envelop, and the abundance of ligamentous and capsular structures in the region, repair of these injuries can be a challenge. The classification systems used to describe these injuries aid in describing the mechanism of injury or displacement type present, which may aid in determining what treatment modality can provide the best outcome.

Arthroscopic repair of type II superior labrum anterior posterior (SLAP) lesions in patients over the age of 45 years: a prospective study

BACKGROUND

Superior labrum anterior posterior (SLAP) lesions are a well-defined cause of shoulder pain and disability and may occur in conjunction with rotator cuff tears. This study was designed to prospectively evaluate the minimum 2 year results of arthroscopic repair of type II SLAP lesions in patients over the age of 45 years with and without rotator cuff tears.

PATIENTS AND METHODS

Thirty-five patients with symptomatic type II SLAP lesions were enrolled in the study. All patients underwent arthroscopic SLAP repair and simultaneous repairs were carried out in 17 of these patients who had concomitant full-thickness rotator cuff tears. Patients were grouped into two with regard to the presence of rotator cuff tears. The outcome was assessed by University of California at Los Angeles (UCLA) score and clinical examination (forward flexion/internal rotation/external rotation).

RESULTS

At an average follow-up of 2.5 years, both groups displayed significant improvements in UCLA score (31.2 vs. 11.8; p < 0.01) and range of motion. Compared with the group that had SLAP and concomitant rotator cuff tears, patients in isolated SLAP group had significantly better scores in function (9.4 vs. 8.6; p = 0.045) and patient satisfaction (4.9 vs. 4.5; p = 0.039). No significant difference was found between two groups with respect to range of motion.

CONCLUSIONS

The arthroscopic repair of symptomatic type II SLAP lesions yields favorable outcomes in patients over 45 years of age and the presence of accompanying rotator cuff tears has a negative effect on the results.

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.

The Lisfranc joint

The Lisfranc joint encompasses 6 articulations, weak dorsal ligaments, and strong plantar ligaments. The Lisfranc ligament serves to secure the second metatarsal in the keystone of the midfoot. Traumatic ligament injury and fracture can result in deformity, instability, pain, and degenerative joint disease of the Lisfranc joint. Increased awareness of Lisfranc joint anatomy and advanced imaging has allowed more accurate diagnosis and treatment of this injured joint complex. Nontraumatic degenerative joint disease can also result from congenital and acquired deformity such as first ray insufficiency, abnormal metatarsal parabola, and equinus. Open reduction with internal fixation (ORIF) demands accurate anatomic alignment to prevent the need for salvage arthrodesis. Early studies have shown that primary arthrodesis of the medial 3 rays has performed equally well or better than ORIF for the displaced primarily ligamentous and severe injuries. A paradigm shift may emerge as more studies favor primary arthrodesis.

Midfoot arthritis

Midfoot arthritis is a common cause of significant pain and disability. Although the medial tarsometatarsal (TMT) joints provide < 7 degrees of sagittal plane motion, the more mobile lateral fourth and fifth TMT joints provide balance and accommodation on uneven ground. These small constrained TMT joints also provide stability and translate the forward propulsion motion of the hindfoot and ankle joint to the forefoot metatarsophalangeal joints from heel rise to toe-off. Posttraumatic degeneration is the primary cause of midfoot arthritis, although primary degeneration and inflammatory conditions can also affect this area. The result is a painful midfoot that can no longer effectively transmit load from the hindfoot to the forefoot. Shoe modifications and orthotic inserts are the mainstay of nonsurgical management. Successful management of midfoot arthritis with orthoses is predicated on achieving adequate joint stabilization while still allowing function. Surgical intervention typically involves arthrodesis of the medial midfoot, although the best treatment of the more mobile lateral column is a subject of debate.

Superior labral tears of the shoulder: pathogenesis, evaluation, and treatment

Lesions of the superior glenoid labrum and biceps anchor are a well-recognized cause of shoulder pain. Advances in shoulder arthroscopy have led to improvements in recognizing and managing superior labral anterior-posterior (SLAP) tears. Recent biomechanical studies have postulated several theories for the pathogenesis of SLAP tears in throwing athletes and the effect of these injuries on normal shoulder kinematics. Advances in soft-tissue imaging techniques have resulted in improved accuracy in diagnosing SLAP tears. However, the diagnosis of clinically relevant SLAP tears remains challenging because of the lack of specific examination findings and the frequency of concomitant shoulder injuries. Definitive diagnosis of suspected SLAP tears is confirmed on arthroscopic examination. Advances in surgical techniques have made it possible to achieve secure repair in selected patterns of injury. Recent outcomes studies have shown predictably good functional results and an acceptable rate of return to sport and/or work with arthroscopic treatment of SLAP tears.

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.

MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament

OBJECTIVE

The objective of this study was to assess the utility of MRI in diagnosing injury to the first interosseous cuneometatarsal (Lisfranc) ligament and to additionally determine the associated patterns of traumatic soft tissue and osseous injury.

MATERIALS AND METHODS

Fifteen patients (16 feet) who were referred for MRI evaluation of the Lisfranc ligament, and had operative exploration or examination under anesthesia, were included for analysis. Standard non-contrast MRI foot imaging was performed in all cases. Evaluation of the following components was performed: the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal metatarsal ligaments, soft tissue edema and fluid, and bone marrow edema and fractures. Surgical reports were regarded as the reference standard in all cases.

RESULTS

Seven of 10 cases of grade 3 Lisfranc ligament injuries at surgery were correctly graded at MRI. No cases of surgically proven complete Lisfranc ligament tears (grade 3) were interpreted as normal at MRI. All Lisfranc ligament sprains (grade 2 or 3) at surgery were detected at MRI. Two of six cases reported as grade 1 injuries at MRI were normal at surgery. No cases of surgically proven normal or sprained Lisfranc ligaments were interpreted as grade 3 tears on MRI. Four of six of our cases of normal or sprained Lisfranc ligaments demonstrated fractures; while the minority of complete Lisfranc ligament tears (3/10) contained fractures.

CONCLUSION

MRI is reasonably accurate at detecting traumatic injury to the Lisfranc ligament. However, in clinically suspected cases of traumatic Lisfranc ligament injury, true positive rate for sprain is low.

SLAP lesions: an update on recognition and treatment

Superior labral tears (SLAP lesions) can pose a significant challenge to orthopaedic surgeons and rehabilitation specialists alike. Although advancement in arthroscopic techniques has enhanced arthroscopic repair of SLAP lesions, the clinical diagnosis of SLAP lesions can still be difficult. There is a variety of etiologic factors associated with SLAP lesions and a thorough clinical evaluation is crucial to make the diagnosis. Concomitant injury to the capsular-labral complex or rotator cuff is not uncommon and can further confuse the clinical presentation. The purpose of this paper is to review the pathomechanics, diagnosis, and treatment of SLAP lesions. We will specifically review some of the physical examination tests that are used to diagnose SLAP lesions and report on our technique of arthroscopic repair. Additionally, we will discuss the operative management of associated intra-articular pathology and, finally, we will briefly discuss our postoperative rehabilitation guidelines.

LEVEL OF EVIDENCE

Level 5.

Percutaneous fixation of forefoot, midfoot, hindfoot, and ankle fracture dislocations

Open reduction with rigid internal fixation is the basic principle for surgical management in foot and ankle trauma. High-risk patients present a surgical dilemma for the foot and ankle surgeon because the possible complications are magnified in this patient population. Percutaneous fixation is a unique alternative for achieving anatomic stabilization without increased physical strain to the patient. The significant advantages of percutaneous fixation include minimizing damage to the vascular supply, maintaining and preserving a stable soft tissue envelope, and decreasing the potential risk for infection. This article provides an overview of percutaneous surgical fixation methods and their role in foot and ankle trauma for the high-risk patient.

Avaliação do tratamento cirúrgico da fratura-luxação de Lisfranc

Estudo retrospectivo de 19 casos de fratura-luxação de Lisfranc tratados cirurgicamente no período de 1995 a 2003. O tempo de acompanhamento foi de 35 meses (variando de 4 a 97 meses). O tratamento cirúrgico foi realizado no dia do trauma em 14 casos, com média de demora de 4,78 horas. Ocorreram 5 lesões expostas (36,32%) e 5 pacientes foram vítimas de politraumatismo. O mecanismo de lesão mais freqüente foi o acidente motociclístico, seguido da queda de animais e de altura. Utilizou-se a avaliação funcional proposta pela AOFAS (The American Orthopaedic Foot And Ankle Society), que apresentou média de 77,53 (variou de 44 a 100). Houve relação entre a qualidade da redução obtida e o resultado do tratamento (p = 0,0449) e entre o fato do pacientes ser vítima de politraumatismo e um resultado inferior do escore AOFAS (p= 0.0143). Houve como complicação a presença de Osteoartrose em 8 casos (42,10%), confirmando-a como a principal complicação radiográfica destas lesões. Sua ocorrência foi analisada comparando-se com a qualidade da redução e com os diferentes tipos de lesão (exposta,lesão ligamentar ou fratura, se lesão isolada ou politraumatismo) não encontrando relação com significância estatística (p < 0,005).

Lisfranc injury: how frequently does it get missed? And how can we improve?

Lisfranc injuries are sometimes easily missed especially if they present in a subtle form. In this study, we have tried to measure the level of accuracy of plain radiographs in detecting this type of injury. We have selected 30 sets of foot radiographs with various diagnoses. Eighteen of them had a Lisfranc type of injury which was confirmed by operative findings or further imaging. These radiographs, together with a small diagnostic questionnaire, were presented to nine senior clinicians. We found that only 11 of the 18 cases (61%) were detected by all the readers. Eight of nine readers (90%) missed one particular case of subtle Lisfranc injury in a diabetic neuropathic foot. One case of a divergent injury was missed by five readers (56%). Another case with a coexistent Frieberg's disease was missed by three readers (33%). The mean accuracy for all injuries was 87% (95% confidence interval (CI) 84.6-89.9%). The mean accuracy level for detection of Lisfranc injury among the whole series was 92% (CI 89-95%). We think that the presence of a strong clinical index of suspicion or the presence of impaired pain sensation, further imaging is a must to avoid missing this type of injury at early presentation, and consequently the long term poor prognosis.

Lisfranc joint injuries

Injuries to the tarsometatarsal (Lisfranc's) joint can be difficult injuries to diagnose. Some authors report that up to 20% of injuries are wrongly diagnosed. There remains controversy as to adequacy of closed reduction and fixation compared to open reduction with anatomical reduction and fixation. This article considers the anatomy, mechanism of injury, clinical diagnosis, radiological evaluation, classification, treatment and outcome of this injury pattern.

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.