Lisfranc fracture-dislocations: current management

Clinical outcomes of Tightrope system in the treatment of purely ligamentous Lisfranc injuries

Background

Purely ligamentous Lisfranc injuries are mainly caused by low energy damage and often require surgical treatment. There are several operative techniques for rigid fixation to solve this problem clinically. This study evaluated the effect of using the Tightrope system to reconstruct the Lisfranc ligament for elastic fixation.

Methods

We retrospectively analyzed 11 cases with purely ligamentous Lisfranc injuries treated with the Tightrope system from 2016 to 2019, including 8 male and 3 female. X-ray was performed regularly after operation to measure the distance between the first and second metatarsal joint and the visual analogue scale (VAS) score was used to evaluate pain relief. American orthopedic foot & ankle society (AOFAS) and Maryland foot score were recorded at the last follow-up.

Results

The average follow-up time was 20.5 months (range, 17–24). There was statistically significant difference in the distance between the first and second metatarsal joint and VAS score at 3 months, 6 months, and the last follow-up when compared with preoperative values (P < 0.05).Mean of postoperative AOFAS mid-foot scale and Maryland foot score were 92.4 ± 4.3, 94.1 ± 3.5, respectively. The Tightrope system was not removed and the foot obtained better biomechanical stability. No complications occurred during the operation.

Conclusion

Tightrope system in the treatment of purely ligamentous Lisfranc injuries can stabilize the tarsometatarsal joint and achieve satisfactory effect.

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.

The transverse arch in the human feet: A narrative review of its evolution, anatomy, biomechanics and clinical implications

The dominant characteristics of the human foot are its shock-absorbing capability during walking or gait cycle and its adaptation to uneven surfaces. On the stance phase of the gait, the foot has to be flexible at first for shock absorption and adapt to the terrain; whereas, during the propulsive phase, it has to be dynamically rigid to function as a lever. Foot flexibility and rigidity are mainly controlled at the subtalar and midtarsal joints by tendons and ligaments. The subtalar joint is part of the longitudinal arch, but the midtarsal joint along with the tarsometatarsal joint are components of the transverse arch. However, the existence and functional role of transverse arch in human was challenged by some authors. But recent studies have revealed that the transverse arch has a predominant role in midfoot stiffness (Venkadeshan et al., 2020, & Holowoka et al., 2017). This midfoot stiffness allows the human foot to store elastic energy at the time of heel strike, which is utilized during the push-off mechanism for propulsion, thus making bipedalism more energy-efficient. Moreover, the transverse arch allows the longitudinal arch to be flexible like a lever and, at the same time, makes the arch of the foot rigid to behave like a stiff spring lever. Understanding the role of the transverse arch is obligatory to study the biomechanics of foot injuries and Charcot or diabetic foot. Studies on diabetic foot have shown that the modulation of transverse arch biomechanics and off-loading modalities would improve outcomes in the form of wound-healing and prevention of re-ulceration.

Dislocation of the first metatarsophalangeal joint concomitant with Lisfranc joint dislocation in a 45-year-old man

A 45-year-old man presented with severe pinch-point crush injury to his left foot. Plain radiographs revealed dislocation of the first metatarsophalangeal joint and dorsolateral dislocation of the basal phalanx and sesamoids. The first tarsometatarsal joint was subluxed in the plantar direction and the second to fourth tarsometatarsal joints were subluxed dorsally. The sesamoids were displaced dorsolateral to the metatarsal head. There was a longitudinal tear of the joint capsule at the medial margin of the medial sesamoid, which was sutured together with the abductor hallucis tendon and collateral ligament. The Lisfranc and dorsal ligaments in the tarsometatarsal joint were torn and repaired after reduction and fixed with a plate. One year after surgery, there was contracture of the first metatarsophalangeal joint, but the patient had no pain and was able to run.

A mid-term follow-up retrospective evaluation of tarsometatarsal joint fracture-dislocations treated by closed reduction and percutaneous K-wires fixation

INTRODUCTION

Injuries involving the tarsometatarsal (TMT) joint are relatively uncommon, and the surgical treatment is potentially characterized by a high complications rate. The purpose of this study is to evaluate the results of the treatment of Lisfranc fracture-dislocations treated with closed reduction and percutaneous fixation with K-wires, considering complications and re-intervantion rate.

MATERIALS AND METHODS

A retrospective review was performed on all patients undergone closed reduction and percutaneous fixation with K-wires of a Lisfranc fracture-dislocation. Patients have been clinically evaluated at last follow up by American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Visual Analogue Scale (VAS), as well as by radiograph assessment.

RESULTS

Following inclusion and exclusion criteria, 15 patients have been included, with a mean age of 48.2 ± 5.6 years. Average follow-up was 3.8 ± 1.8 years (range 1-6). 7 fractures analyzed were classified as type A, 7 as type B (3 were B1, 4 were B2) and 1 as type C1. No case of loss of reduction has been observed at radiographic 1-month follow-up. At last follow-up mean AOFAS midfoot score and VAS score were respectively 82.2 ± 10.4 and 1.5 ± 1.3. Registered complications showed one deep vein thrombosis and 2 cases of complex regional pain syndrome (CRPS). One patient subsequently underwent arthrodesis of the tarsometatarsal joint for post-traumatic arthritis.

CONCLUSIONS

The treatment of the fracture-dislocations of the Lisfranc joint by percutaneous reduction and fixation with K-wire can achieve good clinical outcomes with a low rate of complications and reoperations.

LEVEL OF EVIDENCE

Level IV.

Elective removal of metalwork following Lisfranc injury fixation: Results of a national consensus survey of practice

No consensus exists regarding whether metalwork should be routinely removed following fixation of a Lisfranc injury. When metalwork is removed, notable variation in the timing of surgery is reported in current literature. With the support of the British Orthopaedic Foot & Ankle Society (BOFAS) and the Orthopaedic Trauma Society (OTS) an online 10-question survey was distributed and completed by a total of 205 consultant surgeons in the UK between April-June 2020. Excluding the 20 consultant responses from a regional pilot survey, 185 responses were used to form the main analysis. Over one third (69/183, 37.7%) of surgeons reported they routinely remove metalwork following Lisfranc injury fixation at a median time of 6 months post fixation (interquartile range 4-10). The two most commonly chosen reasons for removal of metalwork were 'to optimise physiological function' and 'to reduce the risk of broken metalwork and risk of making subsequent surgery more difficult' (55/78 responses, 70.5%). Over two thirds of survey respondents (126/184, 68.5%) expressed interest to participate in a randomised controlled trial to compare outcomes of metalwork retention versus removal following Lisfranc injury fixation. Community clinical equipoise exists nationally regarding routine metalwork removal following Lisfranc injury fixation. Considering the paucity of literature, the current survey supports the development of a randomised controlled trial to establish the risks and benefits of metalwork retention versus removal, and would be of value to foot & ankle and trauma surgeons in the UK.

Percutaneous reduction and fixation of low energy Lisfranc injuries results in better outcome compared to open reduction and internal fixation: Results from a matched case-control study with minimum 12 months follow up

BACKGROUND

Percutaneous fixation of Lisfranc injuries is potentially less invasive to traditional open techniques but evidence of any clinical benefit is lacking. The aim of this study is to compare the clinical outcomes of percutaneous reduction and internal fixation (PRIF) of low energy Lisfranc injuries with a matched, control group of patients treated with ORIF.

METHODS

Over a seven-year period (2012-2019), 16 consecutive patients with a low energy Lisfranc injury (Myerson B2-type) were treated with PRIF. Patient demographics, injury mechanism and radiological outcomes were recorded within a prospectively maintained database at the institution. This study sample was matched for age, sex and mechanism of injury to a control group of 16 patients with similar low energy Lisfranc injuries (Myerson B2-type) treated with ORIF. Clinical outcome was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ).

RESULTS

At a mean follow up of 43 months (95% CI 35.6 - 50.4), both the AOFAS and MOXFQ scores were significantly higher in the PRIF group compared to the control ORIF group (AOFAS 89.1vs 76.4, p=0.03; MOXFQ 10.0 vs 27.6, p=0.03). There were no immediate postoperative complications in either group. There was no radiological evidence of midfoot osteoarthritis in the PRIF group, three patients in the ORIF group developed midfoot osteoarthritis (p=0.2).

CONCLUSIONS

PRIF of low energy Lisfranc injures is a safe, minimally invasive technique and is associated with better mid-term clinical outcomes compared to ORIF.

Sports-Related Lisfranc Injuries and Recognition of Lisfranc Variants: Surgical Strategies for Stabilization

Much has changed since Lisfranc described lesions at the tarsometatarsal (TMT) joint in 1815. What was considered an osseous high-energy condition nowadays is understood as myriad possible presentations, occurring in minor and inconspicuous traumas. Advancements in diagnostics of Lisfranc injury allow recognizing many variants of this trauma presentation, most of them with a focus on ligaments. This perception shifted trends in surgical planning, especially for implants and fixation techniques. These revolutions established a new and evolving universe around TMT lesions, different from what was known only a few years ago and still not enough to completely settle the disease scenario.

Primary Arthrodesis for High-Energy Lisfranc Injuries

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

[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.

Os intermetatarseum: An analysis of morphology and case reports of fracture

INTRODUCTION

The os intermetatarseum is an uncommon accessory ossicle of the foot located dorsally, between the bases of the first and second metatarsals that are usually asymptomatic. In the setting of trauma, this ossicle can clinically mimic a Lisfranc fracture-dislocation, a potentially disabling condition often requiring surgical intervention.

METHODS

In this study, 47 cases of os intermetatarseum were reviewed across several Western Australian (WA) Hospitals and characterised based on morphology. Any fractures were recorded, and their cases were reviewed.

RESULTS

The most common type of os intermetatarseum was freestanding at 63%, followed by the articulating type at 30%. Only 7% were of the fused type. Two acute fractures were identified on plain radiography and computed tomography (CT).

CONCLUSION

The distribution of os intermetatarseum subtypes in the WA population is consistent with previous radiological studies. The two cases of isolated acute os intermetatarseum fracture are described, the first to our knowledge, highlighting the need for increased awareness of this ossicle in the setting of foot trauma.

Morphological characteristics of the Lisfranc ligament

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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