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Ponkilainen V, Mäenpää H, Laine HJ, Partio N, Väistö O, Jousmäki J, Mattila VM, Haapasalo H. Open Reduction Internal Fixation vs Primary Arthrodesis for Displaced Lisfranc Injuries: A Multicenter Randomized Controlled Trial. Foot Ankle Int 2024; 45:612-620. [PMID: 38482816 DOI: 10.1177/10711007241232667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
BACKGROUND There is no consensus whether the primary surgical method should be open reduction and internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries. The aim of our randomized controlled trial was to compare ORIF and PA for displaced Lisfranc injuries. METHODS This study was a national multicenter randomized controlled trial. Altogether 43 displaced Lisfranc injuries were enrolled in this trial. The primary outcome measure was Visual Analogue Scale Foot and Ankle (VAS-FA) at a 24-months follow-up. The secondary outcome measures were VAS-FA pain, function, and other complaints subscales and the American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot Scale. All outcomes were measured at 6, 12, and 24 months. We were unable to reach the planned sample size of 60 patients; thus, the study remains underpowered. RESULTS The mean VAS-FA Overall score in the ORIF group was 86.5 (95% CI 77.9, 95.1) and 80.1 (95% CI 72.0, 88.1) in the PA group at the 24-month follow-up. We did not find eligible evidence of a difference in VAS-FA Overall scores (mean between-group difference 6.5 [95% CI -5.3, 18.2], Cohen d = 0.100). CONCLUSION We did not find evidence of a difference in VAS-FA between ORIF and PA in patients with displaced Lisfranc injuries, and thus both are viable options for the initial surgical method. The trial is underpowered; however, the data may be included in a meta-analysis of similarly designed randomized controlled trials.ClinicalTrials.gov identifier: NCT02953067 24 October 2016.
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Affiliation(s)
- Ville Ponkilainen
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | - Heikki Mäenpää
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | | | - Nikke Partio
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
| | - Olli Väistö
- Department of Orthopaedics and Traumatology, Seinäjoki Central Hospital, Seinäjoki, Finland
| | | | - Ville M Mattila
- Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland
- COXA Hospital for Joint Replacement, Tampere, Finland
- Faculty of Medicine and Life Sciences, University of Tampere, Tampere, Finland
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Hosokawa T, Ikoma K, Maki M, Kido M, Hara Y, Sotozono Y, Takahashi K. Relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in patients with hallux valgus. Mod Rheumatol 2024; 34:410-413. [PMID: 36688576 DOI: 10.1093/mr/road009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/12/2022] [Accepted: 01/04/2023] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Hallux valgus is associated with tarsometatarsal arthritis; its pathophysiology remains unknown. Therefore, we aimed to elucidate the relationship between arthritis of the second and third tarsometatarsal joints and incongruity of the first tarsometatarsal joint in the sagittal plane. METHODS Forty-three patients (64 feet) with hallux valgus who underwent surgery at University Hospital Kyoto Prefectural University of Medicine were included and divided into two groups: control (without second and third tarsometatarsal joint degeneration) and osteoarthritis (with second and third tarsometatarsal joint degeneration). Intergroup comparisons of the incongruity of the first tarsometatarsal joint in the sagittal plane, age, body mass index, hallux valgus angle, first-second intermetatarsal angle, metatarsus adductus angle, Meary's angle, and calcaneal pitch angle were performed. RESULTS The proportion of patients with incongruity of the first tarsometatarsal joint was significantly higher in the osteoarthritis group than in the control group. Logistic regression analysis identified incongruity of the first tarsometatarsal joint and metatarsus adductus angle as significant related factors for arthritis of the second and third tarsometatarsal joints. CONCLUSIONS Incongruity of the first tarsometatarsal joint in the sagittal plane was involved in the development of arthritis of the second and third tarsometatarsal joints in patients with hallux valgus.
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Affiliation(s)
- Toshihiro Hosokawa
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kazuya Ikoma
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiro Maki
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masamitsu Kido
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yusuke Hara
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Yasutaka Sotozono
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kenji Takahashi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Rammelt S, Murillo PAC. Lisfranc Arthrodesis in Posttraumatic Chronic Injuries. Foot Ankle Clin 2022; 27:745-767. [PMID: 36368795 DOI: 10.1016/j.fcl.2022.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic injuries at the tarsometatarsal joint represent a wide array of painful malunions ranging from isolated instability to complex three-dimensional deformities with rapid development of posttraumatic arthritis. Deformity correction and arthrodesis of the symptomatic joints leads to significant pain reduction and functional improvement provided that realignment of the anatomic axes is achieved. Arthrodesis should be limited to the first to third tarsometatarsal joints, whereas interposition arthroplasty is preferred for symptomatic arthritis of the fourth to fifth tarsometatarsal joints. For complex deformities and instability, the intercuneiform and naviculocuneiform joints may need to be included into corrective fusion.
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Affiliation(s)
- Stefan Rammelt
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl-Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany.
| | - Pablo Andrés Cárdenas Murillo
- University Center for Orthopaedics, Trauma and Plastic Surgery, University Hospital Carl-Gustav Carus at TU Dresden, Fetscherstrasse 74, Dresden 01307, Germany
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Shim DW, Choi E, Park YC, Shin SC, Lee JW, Sung SY. Comparing bilateral feet computed tomography scans can improve surgical decision making for subtle Lisfranc injury. Arch Orthop Trauma Surg 2022; 142:3705-3714. [PMID: 34599354 DOI: 10.1007/s00402-021-04182-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/01/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Subtle Lisfranc injuries (SLIs) are challenging to diagnose. Although weightbearing (WB) radiographs have been suggested to identify SLIs, approximately 20% are missed on initial radiographic assessment. Computed tomography (CT) has been suggested as an alternative, but has not provided any diagnostic guideline. Therefore we compared measurement techniques on radiographs and bilateral foot CT scans for the efficiency of diagnosis and making surgical decisions for SLI. METHODS We retrospectively investigated patients diagnosed with SLIs between January 2014 and January 2020. Distances between both medial cuneiform and second metatarsal base (C1M2), and the first and second metatarsal bases (M1M2), were measured on bilateral WB radiographs. Bilateral foot CT scans were taken, and the distances between C1M2 were checked on the axial and three points of the coronal plane (top, middle, and base). The surgical indication was > 1 mm of diastasis on CT scan. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score at final follow-up. Intraobserver and interobserver agreements were assessed. RESULTS Thirty patients with SLIs were reviewed. Twenty-four patients underwent surgical fixation (Group A) and six patients were treated conservatively (Group B). The side-to-side difference (STSD) of C1M2 and M1M2 distances greater than 1 mm showed 91.7% and 54.2% sensitivity, and 66.7% and 16.7% specificity, respectively. Investigating STSDs of all points on CT scans were informative to discriminate both groups (P ≤ 0.038). Clinical outcomes showed no significant difference between the groups (P = 0.631). Intraclass and interclass correlation coefficient values showed good to very good reliability, except for STSD of WB M1M2 distance and the coronal top plane. CONCLUSION Investigating bilateral foot CT scans was significantly efficient and reliable for the diagnosis and treatment plan for SLI. On radiographs, STSD of WB C1M2 distance was more sensitive than STSD of WB M1M2 distance. LEVEL OF EVIDENCE Case control study; III.
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Affiliation(s)
- Dong Woo Shim
- Department of Orthopedic Surgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, 25, Simgok-ro 100beon-gil, Seo-gu, Incheon, 22711, South Korea
| | - Eunyoung Choi
- Student, Catholic Kwandong University College of Medicine, 7, Simgok-ro 100beon-gil, Seo-gu, Incheon, 22711, South Korea
| | - Young-Chang Park
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, South Korea
| | - Sung Chul Shin
- Department of Orthopedic Surgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, 25, Simgok-ro 100beon-gil, Seo-gu, Incheon, 22711, South Korea
| | - Jin Woo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Seung-Yong Sung
- Department of Orthopedic Surgery, International St. Mary's Hospital, Catholic Kwandong University College of Medicine, 25, Simgok-ro 100beon-gil, Seo-gu, Incheon, 22711, South Korea.
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Choi JY, Yu OJ, Suh JS. Factors influencing postoperative residual diastasis after the operative treatment of acute Lisfranc fracture dislocation. Arch Orthop Trauma Surg 2022; 142:2685-2694. [PMID: 34244876 DOI: 10.1007/s00402-021-04058-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/03/2021] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Clinically, surgeons may frequently encounter residual diastasis between the medial cuneiform and 2nd metatarsal base after the operative treatment of acute Lisfranc fracture dislocations. The purpose of this study was to identify factors influencing postoperative residual diastasis. We specifically focused on the preoperative fracture pattern using 3-dimensional computed tomography (3D-CT). MATERIALS AND METHODS Radiographic and clinical findings of 66 patients who underwent operative treatment for acute Lisfranc fracture dislocation were reviewed. Patients were grouped according to residual diastasis evaluated by weight-bearing anteroposterior radiograph of the foot at the final follow-up. Residual diastasis was defined as distance between the medial cuneiform and 2nd metatarsal base greater than the distance on the contralateral side by 2 mm or more. Demographic parameters and fracture patterns based on preoperative foot 3D-CT were compared. A paired t test was used to compare continuous numeric parameters, while a Chi-square test was used for the proportional parameters. Statistical significance was set at P value less than 0.05 for all analyses. RESULTS The mean age at operation, sex, body mass index, and the rate of underlying diabetes were not significantly different between the two groups (P > 0.05 each). Preoperative foot 3D-CT evaluation showed that the rate of large (> 25% of 2nd tarsometatarsal joint involvement), displaced (> 2 mm) fracture fragments on the plantar side of the 2nd metatarsal base was more pronounced in the group with residual diastasis (P = 0.001), while medial wall avulsion of the 2nd metatarsal base was more frequent in the group without residual diastasis (P = 0.001). CONCLUSIONS While treating acute Lisfranc injuries, surgeons should be aware of the presence of a 2nd metatarsal base plantar fracture. A dorsoplantar inter-fragmentary fixation can be considered if the fragment is large and displaced.
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Affiliation(s)
- Jun Young Choi
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Oh Jun Yu
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea
| | - Jin Soo Suh
- Department of Orthopedic Surgery, Inje University, Ilsan Paik Hospital, 170 Juhwa-ro, Ilsanseo-gu, Goyang-si, Gyeonggi-do, South Korea.
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Ponkilainen VT, Partio N, Salonen EE, Laine HJ, Mäenpää HM, Mattila VM, Haapasalo HH. Outcomes after nonoperatively treated non-displaced Lisfranc injury: a retrospective case series of 55 patients. Arch Orthop Trauma Surg 2021; 141:1311-1317. [PMID: 32960309 PMCID: PMC8295070 DOI: 10.1007/s00402-020-03599-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 09/09/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current knowledge of the role of the nonoperative treatment of Lisfranc injuries is based on a few retrospective case series. Hence, consensus on which patients can be treated nonoperatively does not exist. The aim of this study was to investigate outcomes after nonoperative treatment of Lisfranc injuries. METHODS In this study, patients were collected by recruiting all computer tomography-confirmed Lisfranc injuries treated during a 5-year period at a major trauma hospital. Between 2 and 6 years after suffering the injury, patients completed the visual analogue scale foot and ankle questionnaire. RESULTS In total, 55 patients returned adequately completed questionnaires and were included in the study. Of those, 22 patients had avulsion fractures and 33 had simple non-displaced intra-articular fractures. Of these patients, 30 (55%) scored over 90 points in both the pain and function subscales of the VAS-FA, and 35 (64%) scored over 90 points overall. In addition, three (5%) patients scored under 60 points in both the pain and function subscales of the VAS-FA, and four (7%) scored under 60 points overall. Only one patient with avulsion fractures underwent secondary surgery. CONCLUSION Nonoperative treatment has a role in the treatment of Lisfranc injuries, and the results of our study support the view that avulsion and simple intra-articular fractures with < 2 mm of displacement can be treated nonoperatively with high functional outcomes. The results of nonoperative and operative treatment should be compared in a prospective randomized controlled study setting in future studies. LEVEL OF EVIDENCE IV, retrospective case series.
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Affiliation(s)
- Ville T Ponkilainen
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland.
- University of Tampere, School of Medicine, 33520, Tampere, Finland.
| | - Nikke Partio
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
| | - Essi E Salonen
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
| | | | - Heikki M Mäenpää
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
| | - Ville M Mattila
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
- COXA Hospital for Joint Replacement, Biokatu 6, 33520, Tampere, Finland
| | - Heidi H Haapasalo
- Department of Orthopaedics, Faculty of Medicine and Life Sciences and Tampere University Hospital, University of Tampere, Teiskontie 35, PL2000, 33521, Tampere, Finland
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Asymmetric lambda sign of the second tarsometatarsal joint on axial weight-bearing cone-beam CT scans of the foot: preliminary investigation for diagnosis of subtle ligamentous Lisfranc injuries in a cadaveric model. Skeletal Radiol 2020; 49:1615-1621. [PMID: 32394072 DOI: 10.1007/s00256-020-03445-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/31/2020] [Accepted: 04/05/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Subtle Lisfranc joint injuries remain challenging to diagnose. Although of questionable accuracy, the current gold standard to assess these injuries is through bilateral weight-bearing radiography. However, weight-bearing cone beam-computed tomography (CBCT), providing clearer visualization of bony landmarks, can also be utilized for evaluation. This study aims to establish the hypothesis that a specific weight-bearing CBCT finding (asymmetric lambda sign) can serve as an independent indicator of a subtle Lisfranc injury. METHODS Weight-bearing CBCT images of 24 match-paired cadaveric legs were acquired, initially intact, and then following sequential dissection of each aspect (dorsal, interosseous, and plantar ligaments, respectively) of the Lisfranc ligamentous complex (LLC). All scans were taken in non- (NWB, 0 kg), partial- (PWB, 40 kg), and full-weight-bearing (FWB, 80 kg) manners. The lambda sign was then inspected axially for asymmetry (positive sign) by identifying three symmetrical joint spaces created between the medial cuneiform and the second metatarsal base (C1-M2), the medial and middle cuneiform (C1-C2), and the second metatarsal base and middle cuneiform (M2-C2). RESULTS A positive sign was observed in 25.6% (221/864) of all studies. Most notably, the fully dissected specimens demonstrated an asymmetric lambda sign in 33.3%, 72.2%, and 83.3% in NWB, PWB, and FWB conditions, respectively. The inter- and intra-observer reliability kappa value was calculated to be 0.843 and 0.912. CONCLUSION An asymmetric lambda sign is a simple and useful indicator for a complete LLC injury in PWB and FWB conditions using a cadaver model.
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Sivakumar BS, An VVG, Oitment C, Myerson M. Subtle Lisfranc Injuries: A Topical Review and Modification of the Classification System. Orthopedics 2018; 41:e168-e175. [PMID: 29451936 DOI: 10.3928/01477447-20180213-07] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/13/2017] [Indexed: 02/03/2023]
Abstract
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.].
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Kale DR, Khadabadi NA, Putti BB, Jatti RS. One Month Old Neglected Lisfrancs Fracture Dislocation Treated with Wagner's External Fixator and Percutaneous Screw Fixation : A Case Report. J Orthop Case Rep 2014; 4:42-6. [PMID: 27298958 PMCID: PMC4719373 DOI: 10.13107/jocr.2250-0685.166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Dinesh R Kale
- Jawaharlal Nehru Medical College, 10, Nehru Nagar, Belgaum, Karnataka. India
| | - Nikhil A Khadabadi
- Jawaharlal Nehru Medical College, 10, Nehru Nagar, Belgaum, Karnataka. India
| | - Babu B Putti
- Jawaharlal Nehru Medical College, 10, Nehru Nagar, Belgaum, Karnataka. India
| | - Ravi S Jatti
- Jawaharlal Nehru Medical College, 10, Nehru Nagar, Belgaum, Karnataka. India
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Eleftheriou KI, Rosenfeld PF, Calder JDF. Lisfranc injuries: an update. Knee Surg Sports Traumatol Arthrosc 2013; 21:1434-46. [PMID: 23563815 DOI: 10.1007/s00167-013-2491-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Accepted: 03/26/2013] [Indexed: 12/19/2022]
Abstract
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.
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Abstract
The tarsometatarsal joint complex is an osseous and capsuloligamentous network that includes the 5 metatarsals, their articulations with the cuneiforms and cuboid, and the Lisfranc ligament, a strong interosseous attachment between the medial cuneiform and second metatarsal. A multitude of injury patterns exist involving the tarsometatarsal joint complex; a Lisfranc injury does not delineate a specific injury, but instead a spectrum of processes involving the tarsometatarsal joint complex.
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Affiliation(s)
- Andrew Rosenbaum
- Division of Orthopaedic Surgery, Albany Medical College, Albany, New York, USA
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Abstract
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.
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Abstract
Lisfranc joint injuries may be missed at the time of occurrence potentially leading to persistent instability, deformity, or arthritis. In the absence of significant residual arthritis or fixed deformity, delayed open reduction and internal fixation with or without reconstruction of the Lisfranc ligament may be performed. An alternative is reduction and primary arthrodesis of the relatively immobile medial tarsometatarsal (TMT) joints. In the presence of significant residual arthritis or fixed deformity that is recalcitrant to conservative treatment, arthrodesis, including correction of deformity, is the treatment of choice for the first, second, and third TMT joints. Resection arthroplasty of the fourth and fifth TMT joints may be preferable to arthrodesis in order to maintain physiologic motion.
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Affiliation(s)
- Michael S Aronow
- Department of Orthopaedic Surgery, University of Connecticut Health Center, Medical Arts and Research Building, 263 Farmington Avenue, Farmington, CT 06034-4037, USA.
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Alberta FG, Aronow MS, Barrero M, Diaz-Doran V, Sullivan RJ, Adams DJ. Ligamentous Lisfranc joint injuries: a biomechanical comparison of dorsal plate and transarticular screw fixation. Foot Ankle Int 2005; 26:462-73. [PMID: 15960913 DOI: 10.1177/107110070502600607] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The current treatment of displaced ligamentous injuries of the tarsometatarsal (TMT) joints is open reduction and rigid fixation using transarticular screws. This technique causes further articular surface damage that theoretically may increase the risk of arthritis. Should the screws break, hardware removal is difficult. An alternative method that avoids these potential complications is rigid fixation using dorsal plates. METHODS The displacement between the first metatarsal and medial cuneiform, the second metatarsal and intermediate cuneiform, the first and second metatarsal bases, and the medial cuneiform and second metatarsal base were measured in 10 matched pairs of fresh-frozen cadaver lower extremities in the unloaded and loaded condition. After sectioning the Lisfranc and TMT joint ligaments, measurements were repeated in the loaded condition. The first and second TMT joints of the right feet were fixed with transarticular 3.5-mm cortical screws while those of the left feet with were fixed with dorsal 2.7-mm 1/4 tubular plates. Measurements were then repeated in the unloaded and loaded condition. RESULTS After ligament sectioning, significantly increased first and second TMT joint subluxation with loading was seen. No significant difference was noted with direct comparison between plates and screws with respect to ability to realign the first and second TMT joints and to maintain TMT joint alignment during loading. The amount of articular surface destruction caused by one 3.5-mm screw was 2.0 +/- 0.7% for the medial cuneiform, 2.6 +/- 0.5% for the first metatarsal, 3.6 +/- 1.2% for the intermediate cuneiform, and 3.6 +/- 1.0% for the second metatarsal. CONCLUSIONS The model reliably produced displacement of the first and second TMT joints consistent with a ligamentous Lisfranc injury. Transarticular screws and dorsal plates showed similar ability to reduce the first and second TMT joints after TMT and Lisfranc ligament transection and to resist TMT joint displacement with weightbearing load. CLINICAL RELEVANCE Dorsal plating may be an alternative to transarticular screws in the treatment of displaced Lisfranc injuries.
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Affiliation(s)
- Frank G Alberta
- Active Orthopaedics and Sports Medicine, P.A., Westwood, NJ, USA
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Abstract
Tarsometatarsal joint complex fracture-dislocations may result from direct or indirect trauma. Direct injuries are usually the result of a crush and may involve associated compartment syndrome, significant soft-tissue injury, and open fracture-dislocation. Indirect injuries are often the result of an axial load to the plantarflexed foot. Midfoot pain after even a minor forefoot injury should raise suspicion; up to 20% of tarsometatarsal joint complex injuries are missed on initial examination. An anteroposterior radiograph with abduction stress may reveal subtle injury, but computed tomography is the preferred imaging modality. The goal of treatment is the restoration of a pain-free, functional foot. The preferred treatment is open reduction and internal fixation, using screw fixation for the medial three rays and Kirschner wires for the fourth and fifth tarsometatarsal joints. Satisfactory outcome can be expected in approximately 90% of patients.
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Affiliation(s)
- Michael C Thompson
- Department of Orthopaedic Surgery and Rehabilitation, Creighton-Nebraska Health Foundation, University of Nebraska Medical Center, Omaha, NE 68198-1080, USA
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Chiodo CP, Myerson MS. Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin North Am 2001; 32:11-20. [PMID: 11465123 DOI: 10.1016/s0030-5898(05)70190-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Continued research and clinical advances have allowed clinicians to diagnose injuries of the tarsometatarsal joint earlier and with greater precision than in previous eras and have promoted refinements of the surgical procedures used in their treatment. For patients with such injuries, these advances should result in improved function and a substantial decrease in morbidity.
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Affiliation(s)
- C P Chiodo
- Department of Orthopaedic Surgery, Union Memorial Hospital, Baltimore, Maryland 21218, USA
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Lu J, Ebraheim NA, Skie M, Porshinsky B, Yeasting RA. Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study. Foot Ankle Int 1997; 18:351-5. [PMID: 9208294 DOI: 10.1177/107110079701800608] [Citation(s) in RCA: 77] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Six cadaver feet were used for radiological and computed tomographic (CT) evaluation. The tarsometatarsal joints of each specimen were displaced dorsolaterally in successive 1-mm increments. None of the 1-mm and two thirds of the 2-mm dorsolateral Lisfranc dislocations could be visualized on routine radiographs; they could all be noted on CT scans. There was good assessment on CT scan for the extent of the minor lesions that are normally obscured by overlapping projection in routine radiographs. A Lisfranc injury that appears undisplaced on radiographs or acceptable after closed reduction may still have an unpredictable outcome because of the presence of an occult joint subluxation. CT scanning is more sensitive than radiography for detecting the minor amounts of Lisfranc displacement. If there is any doubt on the radiographs, a CT scan should be performed. The early diagnosis and treatment of Lisfranc injuries may minimize development of post-traumatic degenerative arthritis.
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Affiliation(s)
- J Lu
- Department of Orthopaedic Surgery, Medical College of Ohio, Toledo 43614, USA
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