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.

Case Report: Portable handheld ultrasound facilitates intra-articular injections in articular foot pathologies

Background

Intra-articular injections are commonly used to manage joint pathologies, including osteoarthritis. While conventional ultrasound (US) guidance has generally improved intra-articular injection accuracy, forefoot and midfoot joint interventions are still often performed without imaging guidance. This pilot study aims to evaluate the efficacy of office-based, portable ultrasound (P-US) guided intra-articular injections for forefoot and midfoot joint pain caused by various degenerative pathologies.

Methods

A retrospective analysis was conducted on a series of consecutive patients who underwent P-US guided intra-articular injections following a chief complaint of forefoot or midfoot joint pain. Patients reported their pain levels using the Visual Analog Scale (VAS) pre-injection and at 3 months follow-up. The procedure was performed by an experienced foot and ankle surgeon using a linear array transducer for guidance, and a 25-gauge needle was used to inject a combination of 2 cc 1% lidocaine and 12 cc of Kenalog (40 mg/ml). Complications and pain scores were analyzed using a paired t-test and p < 0.05 was considered significant.

Results

We included 16 patients, 31% male and 69% female with a mean age (±SD) of 61.31 (±12.04) years. None of the patients experienced immediate complications following the intervention. The mean pre-injection VAS score was significantly reduced from 5.21 (±2.04) to a mean of 0.50 (±1.32) at 3 months follow-up (P < 0.001). Thirteen patients reported complete resolution of pain at the 3-month follow-up. No adverse events were reported throughout the duration of the study.

Conclusion

This pilot study suggests P-US-guided intra-articular injections offer a safe and effective method for managing forefoot and midfoot joint pain caused by various arthritic pathologies. Further research is warranted to establish the long-term efficacy and comparative effectiveness of P-US-guided injections in larger patient cohorts as compared to non-image guided injections.

Treatment of Medial Instability of the Carpometacarpal and Tarsometatarsal Joints Using the Isolock® System in Two Dogs

This case report describes a novel procedure using the Isolock Intrauma® implant system for treating medial instability of the carpometacarpal and tarsometatarsal joints, as demonstrated in in two dogs. A 9-year-old spayed female Spanish greyhound presented with a non-weight-bearing right hindlimb following a trauma. The clinical and radiological findings confirmed medial tarsometatarsal instability consistent with valgus deviation of the tarsus and the opening of the joint line on the medial aspect from the first to the third tarsometatarsal joints. A 4-year-old female Drahthaar presented with a non-weight-bearing left forelimb, swelling of the carpus and valgus instability. Radiological examination revealed a widening of the spaces between the intermedioradial carpal bone, second carpal bone and metacarpal bone II, confirming the medial carpometacarpal instability. In both cases, the Isolock system, an implant including ultra-high-molecular-weight polyethylene suture (UHMWPE), was used to reinforce the medial joint structures. Minor short-term complications were observed, such as swelling of the tarsal surgical site and hyperextension of the carpus, but these resolved spontaneously. No lameness or major complications were reported five months postoperatively. Carpometacarpal and tarsometatarsal instabilities are rare diseases in dogs as compared to subluxations of the other joints of the carpus and tarsus. There are no previous reports regarding the use of a UHMPWE implant for the treatment of these rare joint injuries, though the present case report suggests the validity and efficacy of the Isolock Intrauma® implant for restoring carpal and tarsal stability and preserving joint mobility.

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.

Coronal Hindfoot Alignment in Midfoot Charcot Neuroarthropathy

Coronal plane hindfoot malalignment produces abnormal compensatory forces within the midfoot and forefoot. The primary aim of this study is to compare radiographic hindfoot alignment in patients with a midfoot Charcot event, and identify patterns associated with breakdown. A retrospective review of 43 patients (48 limbs) with midfoot Charcot neuroarthropathy were compared between the coronal hindfoot alignments and Charcot joint involvement. Coronal hindfoot alignment was classified as neutral (n = 15), valgus (n = 16), and varus (n = 17) utilizing the Saltzman hindfoot alignment radiograph. Charcot joint breakdown was classified as isolated tarsometatarsal joint (n = 8), combination of tarsometatarsal and naviculocuneiform joints (n = 22), and midtarsal joints including talonavicular and calcaneocuboid joints (n = 18). Patients exhibiting varus hindfoot alignment had 5.8 times greater risk of breakdown at the tarsometatarsal and naviculocuneiform joints (odds ratio 5.8, 95% confidence interval 1.7-22.9, p < .01). Hindfoot varus induces external rotation of the talus, resulting in compensation through the naviculocuneiform and tarsometatarsal joint, which correlates with our findings of a 6-fold increase in naviculocuneiform and tarsometatarsal joint collapse. Patients exhibiting valgus hindfoot alignment had 27 times greater risk of breakdown at the midtarsal joint (odds ratio 27.0; 95% confidence interval 5.6-207.0, p < .01). Hindfoot valgus induces internal rotation of the talonavicular joint, which correlates with our findings of a 27-fold increase in midtarsal joint breakdown. Varus and valgus hindfoot alignment are associated with different midfoot injury patterns, which may have implications in surgical management and allow for focused surveillance in neuropathic patients presenting with early-stage clinical findings consistent with Charcot neuroarthropathy.

Implications of Dorsalis Pedis Artery Anatomical Variants for Dorsal Midfoot Surgery

BACKGROUND

The dorsalis pedis artery (DPA) usually branches into the arcuate artery (AA) from its lateral side which in turn crosses the bases of the lateral four metatarsals. The DPA then passes into the first interosseous space, where it divides into the first metatarsal artery and the deep plantar artery. In this study, we aimed to determine the extent of variation in the DPA and the distance between the AA and the tarsometatarsal (TMT) joint with the aim of reducing the risk of vascular complications arising from dorsal midfoot surgery.

METHODS

In 29 fresh cadaveric feet, we examined the course of the DPA and the distance between the AA and the TMT joint on computed tomography images with barium sulfate contrast.

RESULTS

The DPA was observed to have a standard course in 11 of the 29 cases (37.9%) but did not give rise to the AA and lateral tarsal artery or branches of the plantar arterial arch supplying to the second to fourth metatarsal spaces in 10 of 29 cases (34.5%). The mean closest distance from the TMT joint to the AA at the second, third, and fourth metatarsal level in the sagittal plane was 11.4, 14.6, and 17.1 mm, respectively.

CONCLUSION

We found substantial variation in the arterial anatomy of the DPA system across the dorsal midfoot.

CLINICAL RELEVANCE

The risk of pseudoaneurysm and frank arterial disruption may be mitigated if the surgeon is aware of the variations of the course of the DPA when performing dorsal midfoot surgery.

Lisfranc complex injuries management and treatment: current knowledge

Lisfranc complex injuries are a spectrum of midfoot and tarsometatarsal (TMT) joint trauma, more frequent in men and in the third decade of life. Depending on the severity of the trauma can range from purely ligamentous injuries, in low-energy trauma, to bone fracture-dislocations in high-energy trauma. A quick and careful diagnosis is crucial to optimize management and treatment, reducing complications and improving functional outcomes in the middle and long-term. Up to 20% of Lisfranc fractures are unnoticed or diagnosed late, above all low-energy trauma, mistaken for simple midfoot sprains. Therefore serious complications such as post-traumatic osteoarthritis and foot deformities are not uncommon. Clinically presenting with evident swelling of the midfoot and pain, often associated with joint instability of the midfoot. Plantar region ecchymosis is highly peculiar. First level of examination is X-Ray performed in 3 projections. CT scan is useful to detect nondisplaced fractures and minimal bone sub-dislocation. MRI is the gold standard for ligament injuries. The major current controversies in literature concern the management and treatment. In stable lesions and in those without dislocation, conservative treatment with immobilization and no weight-bearing is indicated for a period of 6 weeks. Displaced injuries have worse outcomes and require surgical treatment with the two main objectives of anatomical reduction and stability of the first three cuneiform-metatarsal joints. Different surgical procedures have been proposed from closed reduction and percutaneous surgery with K-wire or external fixation (EF), to open reduction and internal fixation (ORIF) with transarticular screw (TAS), to primary arthrodesis (PA) with dorsal plate (DP), up to a combination of these last 2 techniques. There is no superiority of one technique over the other, but what determines the post-operative outcomes is rather the anatomical reduction. However, the severity of the injury and a quick diagnosis are the main determinant of the biomechanical and functional long-term outcomes.

A Comparison of Complications and Reoperations Between Open Reduction and Internal Fixation Versus Primary Arthrodesis Following Lisfranc Injury

There is a lack of consensus in the literature regarding optimal treatment methods for Lisfranc injuries, and recent literature has emphasized the need to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA). The purpose of the current study is to compare reoperation and complication rates between ORIF and PA following Lisfranc injury in a private, outpatient, orthopaedic practice. A retrospective chart review was performed on patients undergoing operative intervention for Lisfranc injury between January 2009 and September 2015. A total of 196 patients met the inclusion criteria (130 ORIF, 66 PA), with a mean follow-up of 61.3 and 81.7 weeks, respectively. The ORIF group had a higher reoperation rate than the PA group, due to hardware removal. When hardware removals were excluded, the reoperation rate was similar. Postsurgical complications were compared between the 2 groups with no significant difference. In conclusion, ORIF and PA had similar complication rates. When hardware removals were excluded, the reoperation rates were similar, although hardware removals were more common in the ORIF group compared with the PA group.Levels of Evidence: Level III.

Anatomic Description of the Distal and Intercuneiform Articulations: A Cadaveric Study

The medial, intermediate, and lateral cuneiforms play a pivotal role in foot biomechanics. When correcting deformities of this joint complex understanding the clinical anatomy remains imperative to provide both anatomic reduction and appropriately sized fixation. This study qualitatively and quantitatively describes the distal and intercuneiform articulations and their clinical implications. The cuneiform complex of 10 fresh-frozen cadavers was dissected, and the width of the complex was measured with digital calipers. Following further dissection, the distal articular surface shapes of each cuneiform were described, and the individual heights and widths were measured. The intercuneiform articular facets were described and the protrusion distances, between the medial and lateral cuneiforms with the intermediate cuneiform, were measured. The width of the joint complex was 44.74 ± 3.40 mm. The medial cuneiform height, width, dorsal anterior, and plantar protrusion distances were 32.58 ± 2.77 mm, 14.08 ± 2.26 mm, 8.51 ± 2.17 mm, and 6.66 ± 1.21 mm, respectively. The intermediate cuneiform height and width was 23.05 ± 1.92 mm and 9.59 ± 1.85 mm, respectively. The lateral cuneiform height, width, dorsal, and plantar anterior protrusion distances were 23.38 ± 2.67 mm, 10.98 ± 3.01 mm, and 6.76 ± 1.43 mm, and 4.19 ± 1.10 mm respectively. The anterior surface of the medial, intermediate, and lateral cuneiforms was described as reniform, triangular, and triangular, respectively. The majority of intermediate cuneiforms shared an inverted L-shaped articulation with the medial cuneiform, and a B-shaped articulation with the lateral cuneiform. The shapes and sizes of distal and intercuneiform articulations were described with shared anatomical features across cadavers. Understanding the dimensions of the respective surfaces allows for anatomically appropriate fixation size.

Using area and volume measurement via weightbearing CT to detect Lisfranc instability

Weightbearing CT (WBCT) allows evaluation of the Lisfranc joint under physiologic load. We compared the diagnostic sensitivities of one-dimensional (1D) distance, two-dimensional (2D) area, and three-dimensional (3D) volumetric measurement of the injured Lisfranc joint complex (tarsometatarsal, intertarsal, and intermetatarsal) on WBCT among patients with surgically-confirmed Lisfranc instability. The experimental group comprised of 14 patients having unilateral Lisfranc instability requiring operative fixation who underwent preoperative bilateral foot and ankle WBCT. The control group included 36 patients without foot injury who underwent similar imaging. Measurements performed on WBCT images included: (1) Lisfranc joint (medial cuneiform-base of second metatarsal) area, (2) C1-C2 intercuneiform area, (3) C1-M2 distance, (4) C1-C2 distance, (5) M1-M2 distance, (6) first tarsometatarsal (TMT1) angular alignment, (7) second tarsometatarsal (TMT2) angular alignment, (8) TMT1 dorsal step off distance, and (9) TMT2 dorsal step-off distance. In addition, the volume of the Lisfranc joint in the coronal and axial plane were calculated. Among patients with unilateral Lisfranc instability, all WBCT measurements were increased on the injured side as compared to the contralateral uninjured side (p values:  <.001-.008). Volumetric measurements in the coronal and axial plane had a higher sensitivity (92.3%; 91.6%, respectively) and specificity (97.7%; 96.5%, respectively) than 2D and 1D Lisfranc joint measurements, suggesting them to be the most accurate in diagnosing Lisfranc instability. The control group showed no difference in any of the measurements between the two sides. WBCT scan can effectively differentiate between stable and unstable Lisfranc injuries. Lisfranc joint volume measurements demonstrate high sensitivity and specificity, suggesting that this new assessment has high clinical implications for diagnosing subtle Lisfranc instability.

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.

First Tarsometatarsal Joint Loading After Sequential Correction of Hallux Valgus Using a Proximal Opening Wedge Metatarsal Osteotomy and Distal Soft Tissue Procedure

Background:

The proximal opening wedge osteotomy (POWO) of the first metatarsal (TMT-1) is commonly performed in the operative treatment of hallux valgus. Limited work has been dedicated to study POWO’s effect on the TMT-1 joint, however. The purpose of this study is to evaluate the changes in TMT-1 joint contact stress following POWO of the first metatarsal.

Methods:

Five fresh-frozen cadaveric below-knee specimens (mean age: 73 years) with hallux valgus deformities (mean hallux valgus angle [HVA]: 37.4 ± 8.5 degrees) were studied. The specimens were loaded to 400 N on an MTS servohydraulic load frame. Joint contact characteristics at TMT-1 joint were measured with a Tekscan pressure sensor (Model 6900, 1100 psi; Tekscan Inc, Boston, MA) with various opening wedge sizes of 3, 5, and 7 mm both without and with a distal soft tissue release (DSTR). The contact force, area, and peak contact stress were compared among groups using analysis of variance and post hoc multiple comparisons over the untreated (Dunnett test, P < .05).

Results:

The mean contact force was 47.7 ± 33.5 N for untreated specimens. This increased sequentially with opening wedge size and reached statistical significance for 7-mm opening wedge (129.7 ± 62.3 N, P = .01) and 7-mm wedge + DSTR (134.8 ± 60.5 N, P = .008). The mean peak contact stress was 2.8 ± 1.3 MPa for the untreated specimens and increased incrementally with wedge size to 5.7 ± 3.0 MPa for 7-mm wedge only (P = .03) and 5.6 ± 2.5 MPa for 7-mm wedge + DSTR (P = .05). The contact area increased with corrections, but none reached significance.

Conclusion:

With increasing opening wedge size, loading of the TMT-1 joint increases. Joint stresses higher than 4.7 MPa have been shown to be chondrotoxic, potentially predisposing patients to arthritic joint changes following POWO.

Level of Evidence:

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Deep Peroneal Neurectomy for Midfoot Arthritis

Osteoarthrosis of the tarsometatarsal joint (TMTJ) and naviculocuneiform joint (NCJ) is a common pathology treated by foot and ankle specialists. Arthrodesis is the most widely accepted surgical treatment. Patients that are not candidates for arthrodesis are often left without surgical treatment options. Neurectomy has been described for treatment of upper extremity joint arthrosis but has not been well described in the foot. The deep peroneal nerve innervates the first, second, third TMTJs and NCJ. We present a retrospective case series on the outcomes of patients treated with deep peroneal neurectomy for TMTJ and NCJ arthrosis (N = 34 feet in 26 patients). The median postoperative American Orthopedic Foot and Ankle Society midfoot score was 53 (range 16-75) points. Twenty two (85%) of 26 patients stated that their expectations were met as a result of the deep peroneal neurectomy procedure, and 20 (77%) of 26 patients stated that they would have deep peroneal neurectomy for their symptoms again. There were recurrent symptoms prompting patients to seek additional treatment in 7 (21%) of 34 feet. Recurrent pain is also documented in hand denervation studies and the physiologic explanation remains unclear. Our results suggest that deep peroneal neurectomy is an effective treatment option for TMTJ and NCJ arthritis and may be particularly helpful in patients that are poor candidates for arthrodesis.

[Short-term effectiveness of Endobutton plate in reconstruction of Lisfranc ligament]

Objective

To observe the short-term effectiveness of Endobutton plate in the reconstruction of Lisfranc ligament in tarsometatarsal joint injury.

Methods

Between March 2015 and July 2018, 18 patients with tarsometatarsal joint injuries were treated with Lisfranc ligament reconstruction by Endobutton plate. There were 12 males and 6 females with an average age of 32.5 years (range, 16-55 years). The causes of injury were traffic accident in 8 cases, falling from height in 3 cases, crushing by a heavy objective in 4 cases, and spraining in 3 cases. There were 10 cases of Myerson type A, 4 of type B1, 2 of type B2, 1 of type C1, and 1 of type C2. The interval between injury and operation ranged from 3 to 9 days (mean, 4.9 days). X-ray examination was performed regularly after operation to measure the distance between the first and the second metatarsal joints, and the visual analogue scale (VAS) score was used to evaluate the pain relief. At last follow-up, the reduction of tarsometatarsal joint was evaluated by measuring and comparing the height of the affected and healthy arches. The foot function was evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) score.

Results

The average follow-up time was 15.8 months (range, 10-28 months). All incisions healed by first intention. X-ray reexamination showed that there was no screw loosening or plate fracture. There were significant differences in the distance between the first and the second metatarsal joints and VAS score at 3 months after operation, before removal of the internal fixator, and at last follow-up when compared with preoperative values ( P<0.05). There was no significant difference between the time points after operation ( P>0.05). At last follow-up, there was no significant difference in the arch height between affected foot [(5.3±0.2) mm] and healthy foot [(5.4± 0.3) mm] ( t=1.798, P=0.810). The AOFAS score of foot function was 89.5±7.3 with excellent in 12 cases, good in 4 cases, and fair in 2 cases. The excellent and good rate was 88.9%.

Conclusion

The reconstruction of Lisfranc ligament with Endobutton plate can stabilize the tarsometatarsal joint and achieve satisfactory foot function at early stage.

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.

The association between collagen and bone biomarkers and radiographic osteoarthritis in the distal tarsal joints of horses

BACKGROUND

Osteoarthritis (OA) of the distal intertarsal (DIT) and tarsometatarsal (TMT) joints occurs commonly. Synovial fluid (SF) biomarkers of collagen and bone turnover have potential clinical value.

OBJECTIVES

To measure SF biomarker concentrations from DIT and TMT joints in adult horses and determine if they correlate with radiographic OA severity and are higher in joints with radiographic OA compared to controls.

STUDY DESIGN

Cross-sectional.

METHODS

Radiographic OA of DIT and TMT joints was evaluated from adult horses (5-35 years old). Overall radiographic scores divided horses into those with mild or moderate radiographic OA (16 joints from 9 horses) or controls (13 joints from 9 horses). Direct biomarkers of OA (Carboxypropeptide of type II collagen = CPII, carboxy-neoepitope of type II collagen exposed after collagenase-cleavage = C2C, Bone alkaline phosphatase = BAP and Chondroitin sulfate epitope = CS846) were measured via ELISA and CPII/C2C was calculated. Biomarkers were correlated with radiographic findings and concentrations from those with radiographic OA to control joints and were compared.

RESULTS

Concentrations of CPII (R = 0.84, P<0.001), C2C (R = 0.69, P<0.001) and BAP (R = 0.41, P = 0.03) as well as CPII/C2C (R = 0.69, P<0.001) values positively correlated with overall radiographic scores. Adjusted means ± s.d., after controlling for age, for CPII (P<0.001), C2C (P<0.001), CPII/C2C (P = 0.004) and BAP (P = 0.05) were significantly higher in DIT and TMT joints with radiographic OA (CPII: 2174.45 ± 1064.01; C2C: 233.52 ± 51.187; CPII/C2C: 9.01 ± 4.09; BAP: 21.98 ± 15.34) compared to controls (CPII: 594.53 ± 463.05; C2C: 153.12 ± 48.95; CPII/C2C: 3.96 ± 2.38; BAP: 12.76 ± 3.61). CPII (P<0.001), C2C (P = 0.001) and CPII/C2C (P = 0.001) were significantly higher with moderate radiographic OA (CPII: 2444.61 ± 772.78; C2C: 248.90 ± 44.94; CPII/C2C: 9.47 ± 2.97) compared to controls (CPII: 658.38 ± 417.36; C2C: 156.49 ± 47.61; CPII/C2C: 4.15 ± 2.04), with CPII also showing significantly higher concentrations (P = 0.04) with mild radiographic OA compared (1515.00 ± 584.95) to controls (658.38 ± 417.36). There were no differences in CS846 concentrations between radiographic OA and control joints. Age positively correlated with CPII (R = 0.48, P = 0.01) and C2C (R = 0.44, P = 0.02) concentrations.

MAIN LIMITATIONS

Radiographic OA was assessed, not clinical lameness. Controls were not age-matched to those with spontaneous radiographic OA.

CONCLUSIONS

There is an association between collagen (CPII, C2C and CPII/C2C) and bone (BAP) biomarkers and radiographic OA in the distal tarsal joints of horses.

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

The computed tomographybased anatomy of the ossa cuneiformia

There is a lack of basic anatomic information regarding the ossa cuneiformia. The aim of the present descriptive study was the detailed evaluation of the anatomy of the ossa cuneiformia. We analyzed 100 computer tomography scans of feet without deformities or previous trauma. The length, height and width of each cuneiforme and their articular surfaces were assessed. We itemized the data to gender differences and to foot length. The medial cuneiforme os had a length of 24.0 mm ± 2.4 (mean ± standard deviation), a width of 17.3 mm ± 2.8 and a height of 28.0 mm ± 3.4. The respective values for the intermediate cuneiforme were 18.2 mm ± 2.1, 15.8 mm ± 2.1 and 22.5 ± 2.2 and for the lateral cuneiforme 26.4 mm ± 2.7, 17.2 mm ± 2.9 and 22.8 mm ± 2.9. We found statistical relevant differences regarding gender and foot length subgroups whereas not for all parameters. The present study illustrates basic anatomic data regarding the ossa cuneiformia. This information might be helpful for implant design and placement during midfoot surgery.

Is Routine Hardware Removal Following Open Reduction Internal Fixation of Tarsometatarsal Joint Fracture/Dislocation Necessary?

Open reduction internal fixation (ORIF) is an accepted treatment for displaced tarsometatarsal joint (TMTJ) fracture dislocations. In general, hardware is routinely removed after 4 months to allow restoration of joint motion and avoid complications of hardware failure. Because few studies report outcomes of TMTJ fractures with retained hardware, there is little consensus regarding the optimal time for hardware removal or if hardware retention leads to adverse outcomes. We retrospectively reviewed the radiographic outcomes of retained hardware after ORIF of TMTJ fractures/dislocations in 61 patients. The mean age at the time of operation was 37.3 ± 14.9 years. ORIF was performed with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgical treatment. Out of the 61 patients that were included in this study, only 2 demographic variables demonstrated a trend for an adverse outcome. Older age correlated with lost reduction and elevated body mass index correlated with hardware failure. The presence of diabetes was correlated with an increased risk of postoperative infection but not hardware failure. During our follow-up period there were 49 patients (80.3 %) without failure of fixation. In conclusion, our study suggests that routine removal of hardware following open reduction and internal fixation of Lisfranc injuries in patients may not be necessary.

Surgical Treatment of Lisfranc Injury With Plantar Plate Approach

Midfoot injuries are the second most common athletic foot injury documented in the published data. High-energy Lisfranc dislocations are commonly seen secondary to traumatic etiologies and disrupt the strong midfoot ligaments supporting the arch. These injuries require immediate surgical intervention to prevent serious complications such as compartment syndrome and amputation. The present case series reports a new Lapidus plate system used in 3 patients who underwent arthrodesis procedures for Lisfranc joint dislocation. Three patients in their fourth to fifth decade of life presented with a traumatic injury at the Lisfranc joint and subsequently underwent open reduction and internal fixation using the plantar Lapidus Plate System (LPS; Arthrex, Naples, FL). The LPS was placed in a predetermined safe zone, with measures taken to avoid the insertional points of the tibialis anterior and peroneus longus tendons. Radiographs were obtained for ≤6 months postoperatively and revealed consolidation across the fusion site, intact hardware, and satisfactory alignment. On examination, the corrections were well maintained and free of signs of infection. Clinical evaluation showed no indication of motion within the tarsometatarsal joint and no tenderness to palpation surrounding the fusion sites. All 3 patients successfully returned to their activities of daily living without discomfort or pain. Modern surgical treatment of Lisfranc injuries most commonly includes open reduction and internal fixation, accompanied by arthrodesis. The present case series has demonstrated that the LPS provides relief, stability, and compression of the joint in our small cohort of patients who experienced a traumatic injury to the Lisfranc joint.

Plate Alone Versus Plate and Lag Screw for Lapidus Arthrodesis: A Biomechanical Comparison of Compression

Background. Arthrodesis of the first tarsal metatarsal joint can be accomplished in many ways. The compressive force attained between various constructs remains unclear. This study compares compression achieved through a locking/compression Lapidus plate both with and without the addition of a lag screw. Methods: A dorsal medial Lapidus/locking compression plate (Total Compression Plate System, OrthoPro, Salt Lake City, UT, now Wright Medical) was applied to one cadaveric limb, while the same plate with the addition of a 4.0-mm cannulated lag screw was applied to the contralateral limb for a total of 5 matched pairs of cadaveric specimens. Compressive force was recorded over time and compared between the constructs using a compression sensor (8" FlexiForce Resistive Force Sensor, Phidgets Inc, Calgary, Alberta, Canada). Results: Compression was maintained for 45.4 minutes in the plate only construct, and 317 minutes with the addition of the lag screw (P = .010). The mean time to 50% peak compression for the plate only construct was 4.90 minutes compared with 15.11 minutes for plate with lag screw construct (P = .012). Conclusion: The addition of a lag screw is recommended for extending the length of compression and possibly reducing nonweightbearing time and the risk of nonunion. Levels of Evidence: Level V.

Cost-Effectiveness Analysis of Primary Arthrodesis Versus Open Reduction Internal Fixation for Primarily Ligamentous Lisfranc Injuries

The purpose of the present study was to determine whether surgical intervention with open reduction internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries is more cost effective. We conducted a formal cost-effectiveness analysis using a Markov model and decision tree to explore the healthcare costs and health outcomes associated with a scenario of ORIF versus PA for 45 years postoperatively. The outcomes assessed included long-term costs, quality-adjusted life-years (QALYs), and incremental cost per QALY gained. The costs were evaluated from the healthcare system perspective and are expressed in U.S. dollars at a 2017 price base. ORIF was always associated with greater costs compared with PA and was less effective in the long term. When calculating the cost required to gain 1 additional QALY, the PA group cost $1429/QALY and the ORIF group cost $3958/QALY. The group undergoing PA overall spent, on average, $43,192 less than the ORIF group, and PA was overall a more effective technique. Strong dominance compared with ORIF was demonstrated in multiple scenarios, and the model's conclusions were unchanged in the sensitivity analysis even after varying the key assumptions. ORIF failed to show functional or financial benefits. In conclusion, from a healthcare system's standpoint, PA would clearly be the preferred treatment strategy for predominantly ligamentous Lisfranc injuries and dislocations.

Finite element analysis of locking plate and 1/4 tubular plate for first tarsometatarsal joint fracture-dislocation

Objective

The optimal plate for fixation of tarsometatarsal joint injuries is controversial. The objective of this study was to compare the biomechanical characteristics between a locking plate and 1/4 tubular plate for first tarsometatarsal joint fracture-dislocation.

Method

Finite element analysis was used after establishment of a first tarsometatarsal joint fracture-dislocation model. Two implant simulations using a locking plate and five-hole 1/4 tubular plate were designed to simulate fixation of the fracture-dislocation. The displacement of the first tarsometatarsal articular surface and the stress distribution in the implants were calculated.

Results

A 700-N load was applied to both models. The minimum displacement of the articular surface in the locking plate and 1/4 tubular plate model was 0.6471 mm and 0.3833 mm, respectively. The maximum principal stress in the locking plate and 1/4 tubular plate was 1.212 × 10³MPa and 1.107 × 10³MPa, respectively.

Conclusion

Use of a 1/4 tubular plate is recommended for fixation of first tarsometatarsal joint fracture-dislocation after consideration of other factors such as economical issues.

Epidemiology and Outcomes of Lisfranc Injuries Identified at the National Football League Scouting Combine

BACKGROUND

Lisfranc injuries are challenging to treat and may have a detrimental effect on athletic performance.

PURPOSE

(1) Determine the epidemiological characteristics of Lisfranc injuries at the annual National Football League (NFL) Scouting Combine, (2) define player positions at risk for these injuries, and (3) evaluate the impact that these injuries and radiographic findings have on NFL draft position and performance.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

All players who sustained a Lisfranc injury prior to Combine evaluation between 2009 and 2015 were evaluated. The epidemiological characteristics, player positions affected, treatment methods, and number of missed collegiate games were recorded. Radiographic outcomes were analyzed via Combine radiograph findings, while NFL performance outcomes were assessed for all Lisfranc injuries (2009-2013) compared with matched controls in the first 2 years of play.

RESULTS

A total of 41 of 2162 (1.8%) Combine participants were identified with Lisfranc injuries, of whom 26 of 41 (63.4%) were managed operatively. Players who underwent surgery were more likely to go undrafted compared with players managed nonoperatively (38.5% vs 13.3%, operative vs nonoperative management, respectively; P = .04) and featured a worse NFL draft pick position (155.6 vs 109; P = .03). Lisfranc-injured players when compared with controls were noted to have worse outcomes in terms of NFL draft position (142 vs 111.3, Lisfranc-injured players vs controls, respectively; P = .04), NFL career length 2 years or longer (62.5% vs 69.6%; P = .23), and number of games played (16.9 vs 23.3; P = .001) and started (6.8 vs 10.5; P = .08) within the first 2 years of their NFL career. Radiographs demonstrated that 17 of 41 (41.5%) athletes had residual Lisfranc joint displacement greater than 2 mm compared with the contralateral foot. Lisfranc-injured athletes with greater than 2 mm residual displacement, when compared with matched controls, had worse draft position (156.9 vs 111.2 for Lisfranc-injured players vs controls, respectively; P = .009) and fewer games played (14.4 vs 23.3; P = .001) and started (3.1 vs 10.5; P = .03). Moreover, athletes with greater than 2 mm residual displacement featured worse outcomes across all assessed NFL variables versus athletes with residual displacement of 2 mm or less.

CONCLUSION

Lisfranc injuries identified at the NFL Combine have an adverse effect on an NFL athlete's draft status, draft position, and overall play during initial NFL seasons. In particular, residual displacement of the Lisfranc joint has a detrimental effect on the first 2 seasons of NFL play and may lead to long-lasting negative effects on the athlete's career.

Post-traumatic Arthritis of the Tarsometatarsal Joint Complex: A Case Report

Tarsometatarsal (TMT) arthritis is characterized by instability and pain in the foot. The commonest cause is post-traumatic arthritis. A Lisfranc injury involves the articulation between the medial cuneiform and the base of the second metatarsal, which is considered a keystone to midfoot integrity. Neglected or undertreated injury to the Lisfranc joint complex leads to secondary arthritis and significant disability. We present a case of a young male patient with a two-year-old neglected Lisfranc joint injury and secondary osteoarthritis of the first, second, and fourth TMT joints, which we treated surgically with arthrodesis using screws, with a good functional outcome on final follow-up.

Proximal Opening Wedge Osteotomy Provides Satisfactory Midterm Results With a Low Complication Rate

Hallux valgus is one of the most common foot deformities. Proximal opening wedge osteotomy is used for the treatment of moderate and severe hallux valgus with metatarsus primus varus. However, hypermobility of the first tarsometatarsal joint can compromise the results of the operation, and a paucity of midterm results are available regarding proximal open wedge osteotomy surgery. The aim of the present study was to assess the midterm results of proximal open wedge osteotomy in a consecutive series of patients with severe hallux valgus. Thirty-one consecutive adult patients (35 feet) with severe hallux valgus underwent proximal open wedge osteotomy. Twenty patients (35.5%) and 23 feet (34.3%) were available for the final follow-up examination. The mean follow-up duration was 5.8 (range 4.6 to 7.0) years. The radiologic measurements and American Orthopaedic Foot and Ankle Society hallux-metatarsophalangeal-interphalangeal scores were recorded pre- and postoperatively, and subjective questionnaires were completed and foot scan analyses performed at the end of the follow-up period. The mean hallux valgus angle decreased from 38° to 23°, and the mean intermetatarsal angle correction decreased from 17° to 10°. The mean improvement in the American Orthopaedic Foot and Ankle Society hallux metatarsophalangeal-interphalangeal score increased from 52 to 84. Two feet (5.7%) required repeat surgery because of recurrent hallux valgus. No nonunions were identified. Proximal open wedge osteotomy provided satisfactory midterm results in the treatment of severe hallux valgus, with a low complication rate. The potential instability of the first tarsometatarsal joint does not seem to jeopardize the midterm results of the operation.

MR Imaging Evaluation of the Lisfranc Ligament in Cadaveric Feet and Patients With Acute to Chronic Lisfranc Injury

BACKGROUND

Magnetic resonance (MR) imaging is known to be useful to demonstrate Lisfranc ligament injury. There are few studies that report differences in MR imaging findings of acute or chronic Lisfranc ligament injuries. We applied oblique MR imaging planes parallel to the Lisfranc ligament for better visualization of the entire course of the ligament and assessed the detailed MR imaging appearances of the Lisfranc ligament in cadavers and patients with presumed Lisfranc injuries.

METHODS

Twelve preserved cadaveric feet were examined using a small-diameter surface coil. Long axis, oblique sagittal, and oblique short axis cross sections parallel to the Lisfranc ligament, dorsal ligament, and plantar ligament were obtained. Twenty-six MR examinations from 23 patients with suspected Lisfranc joint injuries were evaluated.

RESULTS

In the cadaveric study, the Lisfranc ligament was satisfactorily visible along its entire course in a single slice on long axis and oblique sagittal MR images. The dorsal ligament and the plantar ligament were visible separately from the Lisfranc ligament in oblique sagittal and oblique short axis planes. In the patient study, 11 MR examinations led to diagnoses of complete tears of the Lisfranc ligament that were acute injuries (3-21 days after trauma) mostly associated with disruption of the dorsal and plantar ligaments. Nine studies led to diagnoses of incomplete tears of the Lisfranc ligament that were chronic injuries (2-14 months after trauma). Recovery of the continuity of the disrupted ligament was observed in 3 patients.

CONCLUSION

MR imaging demonstrated the integrity of the ligaments and was useful for diagnosing an acute Lisfranc injury. Fibrous healing of the torn ligament was observed in a chronic injury.

Endosseous Fixation Device for Lapidus Arthrodesis: Technique, Early Experience, and Comparison With Crossed Screw Fixation

First metatarsal cuneiform joint arthrodesis has been commonly used since the early 1900s for definitive treatment of a variety of conditions involving the medial column of the foot. Early applications of this procedure resulted in a relatively high rate of complications, including malunion and nonunion. We retrospectively examined a novel method of fixation involving an endosseous implant with a nonporous, rough exterior surface and compared it with the traditional crossed screw fixation, considered the standard of care for the procedure. Twenty-one feet in 19 patients served as the control group with crossed screws, and 18 feet in 17 patients served as the trial group using the study device. Null hypothesis testing was used to compare the outcomes parameters between the comparative groups. Postoperatively, the patients were allowed to walk in a prefabricated, removable, below-the-knee cast boot at a mean of 48.3 ± 8.2 days in the control group and 24.4 ± 9.7 days in the trial group. These differences were highly significant (p < .0001). Postoperatively, the patients were allowed to walk in a stiff-soled shoe at a mean of 65.2 ± 8.4 days in the control group and 49.7 ± 19.2 days in the trial group. These differences were also statistically significant (p = .0020). The patients in the control group required revision surgery in 7 of 21 procedures (33%), with 2 patients developing nonunion (9.5%). Only 1 patient in the trial group required revision surgery (5.8%), and no patient developed nonunion. From these results, we believe that the endosseous trial implant is a reliable option for fixation of the first metatarsal cuneiform arthrodesis procedure and might allow for earlier weightbearing with fewer postoperative complications.

Concurrent Lateral Dorsal Cutaneous and Deep Peroneal Intraneural Ganglion Cysts in the Foot

Intraneural ganglion cysts are non-neoplastic collections of mucinous material within the epineurium of peripheral nerves. We present a rare case of 2 intraneural ganglion cysts in separate nerves of the foot, originating from different joints within the same joint complex. Our findings add to the large body of evidence supporting the unifying articular (synovial) theory. We emphasize the importance of delineating the cyst morphology and origins using high-resolution magnetic resonance imaging before surgery and searching for and resecting the articular branch or branches during surgery.

Subtle lisfranc subluxation: results of operative and nonoperative treatment

Subtle Lisfranc instability is typically a low-energy, twisting, axial-loading injury. The present study evaluated the operative treatment of subtle Lisfranc injuries after nonoperative failure. The data from consecutive patients with subtle Lisfranc instabilities were reviewed. Those in whom initial nonoperative treatment had failed underwent surgery. The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score was obtained initially, after nonoperative treatment, and, for those in whom nonoperative treatment had failed, after operative treatment. Of 36 patients enrolled, 16 (44.44%) were successfully treated nonoperatively, and 20 (55.56%) required surgery after nonoperative treatment had failed. Of those treated operatively, 9 (45%) were stabilized with dual screws and 11 (55%) with dual suture buttons. The mean follow-up period was 36 ± 12.2 months. The AOFAS scores significantly improved from the pre- to final post-treatment values. The overall mean pretreatment AOFAS score (62.8 ± 8.84) was significantly lower statistically than the mean overall post-treatment AOFAS score (91.3 ± 8.34; p < .0001). The mean AOFAS score before nonoperative treatment (61.9 ± 9.5) improved to a mean AOFAS score of 75.3 ± 15.8 after nonoperative treatment (p = .0029). The mean preoperative AOFAS score (63.5 ± 8.46) improved to a postoperative AOFAS score of 92.3 ± 8.43 (p < .0001). The mean AOFAS score before nonoperative treatment (61.9 ± 9.5) was not significantly different statistically from the mean preoperative AOFAS score (63.5 ± 8.46; p = .62). The mean AOFAS score after nonoperative treatment (75.3 ± 15.8) was lower than the mean postoperative AOFAS score (92.3 ± 8.43; p < .0001). Of the 9 feet stabilized with dual screws, 7 (77.78%) required screw removal during the observation period. Subtle Lisfranc injuries failing nonoperative treatment were successfully stabilized using either a dual screw or suture button technique.

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

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

Functional progression and return to sport criteria for a high school football player following surgery for a lisfranc injury

Lisfranc injuries are a challenging diagnosis for the sports physical therapist because of the lack of data on how to rehabilitate them properly. To date, the available rehabilitation literature has focused on the mechanism of injury and the conservative management of this injury. Furthermore, there is a lack of consensus on the appropriate testing and return to play criteria for an athlete recovering from this perplexing injury. This case describes a high school athlete whose primary sport was football, but was injured during wrestling. He suffered a Lisfranc injury and subsequently underwent surgical fixation. The purpose of this case report is to focus on the exercise, functional progression, and return to sport criteria utilized after operative treatment of a Lisfranc ligament injury.

LEVEL OF EVIDENCE

V.