Lisfranc fracture-dislocations: current management

Mid-term Radiologic and Clinical Results of Pediatric-adolescent Lisfranc Injuries

INTRODUCTION

The incidence of Lisfranc injury in pediatric-adolescent children is lower compared with adults. There is limited research on adolescent patients in this age group, with only a few case reports of pediatric patients. Furthermore, studies with adequate follow-up are lacking in the literature. This study aims to provide insights into the causes and types of fractures and evaluate mid-term clinical and radiologic outcomes.

METHODS

A retrospective analysis was conducted on pediatric-adolescent patients diagnosed with a Lisfranc injury who underwent surgical treatment between June 2015 and January 2022. Patients underwent open reduction and internal fixation using Kirschner wires and/or screws, had satisfactory imaging, and were followed up for at least 2 years. Radiologic measurements included intermetatarsal distance, meary angle, and calcaneal height angle, done while the patient was standing. Assessments were made using the AOFAS midfoot score, the Oxford Ankle Foot Questionnaire for Children (OxAFQ-C), Visual Analog Scale (VAS) scores, and physical activities.

RESULTS

The study included 14 surgically treated patients with a minimum 2-year follow-up. The average patient age was 12.6 years, with a mean follow-up of 52.4 months. In pediatric cases, crush injury was the predominant trauma type ( P = 0.009). There were no significant differences in calcaneal pitch angle or meary angle between healthy and injured feet ( P = 0.2 and 0.1), but a greater intermetatarsal distance was observed on the injured side ( P = 0.02). The mean Visual Analog Scale (VAS) score was 1.5, the AOFAS midfoot score averaged 91.5, and the OxAFQ-C score averaged 86.3%.

CONCLUSIONS

The mid-term outcomes for this age group were promising compared with adults. The use of Kirschner wires for fixation is more common in younger patients. Crush injuries and complications like compartment syndrome are more prevalent in the pediatric age group.

Is routine implant removal necessary after open reduction internal fixation of Lisfranc injuries? Comparing functional outcomes of routine and on-demand removal: A multicenter study

INTRODUCTION

Lisfranc joint injuries are a severe cause of disruption of foot stability and function, often requiring surgical intervention such as open reduction and internal fixation (ORIF). The necessity of routine implant removal after healing remains controversial. This study aimed to compare functional recovery and postoperative complications among patients undergoing routine, on-demand, or no implant removal following ORIF for Lisfranc fracture-dislocations.

MATERIALS AND METHODS

This multicenter retrospective study analyzed 188 patients treated with ORIF for Lisfranc fracture-dislocations. Patients were divided into three groups: routine removal (RR), on-demand removal (ODR), and no removal (NR). Functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) midfoot score at the final follow-up. Complications were categorized as implant-related or post-removal. AOFAS midfoot scores and complication rates were compared between the three groups.

RESULTS

The median AOFAS midfoot scores at the final follow-up were 92 (IQR 83.00-95.00) in the RR group, 95 (IQR 85.00-95.00) in the ODR group, and 95 (IQR 82.00-95.00) in the NR group, with no significant differences among the three groups (p > 0.05). Implant-related complications were comparable across the groups, although irritation was significantly more frequent in the ODR group (42.9 %) than in the RR (24.4 %) and NR (11.9 %) groups (p = 0.013). Post-removal complications occurred in two cases in the RR group, including one case of loss of correction requiring reoperation.

CONCLUSION

Routine implant removal did not show superior outcomes in functional recovery or complication rates compared to selective removal or retention. Implant retention or selective removal based on individual needs minimizes complications and optimizes patient outcomes.

Classification in 157 patients with Lisfranc injuries using three-dimensional fracture lines and heat map

BACKGROUND

Recently Lisfranc fractures have increased due to increased high-energy injuries from various causes. However, due to incomplete traditional classification, the pattern and distribution of fractures cannot be analyzed in three dimensions. This study examines a novel fracture pattern based on the fracture line and heat map for Lisfranc injuries.

METHODS

We retrospectively analyzed data from CT scans of 157 patients diagnosed with Lisfranc injuries. We extracted the CT data of a healthy adult and created a standard foot model. We performed 3D reconstruction using patients' CT images and superimposed the fracture model onto the standard model for drawing fracture lines. Subsequently, we converted the fracture lines into a heat map for visualization.

RESULTS

The novel classification identifies high-density fracture sites within the tarsometatarsal joint, predominantly localized in the medial and lateral columns. The fracture lines not involving the TMT joint are mainly located in the medial aspect of the first metatarsal trunk and the fifth metatarsal trunk. Additionally, we develop an assessment protocol for Lisfranc injury that incorporates ligament injury, displacement, and fracture.

CONCLUSION

The new classification accurately identifies the different types of fractures in Lisfranc injuries, enabling clinicians to more fully and accurately understand their patients' injuries and assisting them in efficiently making sound decisions to avoid diagnostic delays that can negatively impact postoperative outcomes.

Can early treatment of lisfranc injuries without planned re-intervention be safely performed

The Lisfranc complex is a unique combination of ligamentous and osseous relationships between the medial cuneiform and second metatarsal base that is often injured by high energy mechanisms. Fixation for these injuries is often operative; however, the optimal timing of surgical treatment has been debated. All patients who underwent operative fixation of a Lisfranc injury at a single urban tertiary care center were reviewed. Patient were split into two groups based on timing to fixation with one group being less than 24 h from presentation and a second group being greater than 24 h. There were 58 patients who underwent what was planned as final operative stabilization of their Lisfranc injury in less than 24 h and 41 patients who underwent fixation after more than 24 h. The early treatment of Lisfranc injuries did not lead to significant increases in follow up time, infections, time to weight bearing, union rates, or time to union compared patients treated with delayed fixation. There was a higher rate of superficial infection in the early intervention group, but it did not reach statistical significance. We believe our findings demonstrate that delayed fixation is not superior to early treatment of Lisfranc injuries.

A rare Lisfranc-type injury involving dorsal dislocation of the intermediate cuneiform and second metatarsal

Lisfranc injuries, involving the tarsometatarsal joints, are rare and account for approximately 0.2% of all fractures. Among these, dorsal dislocation of the intermediate cuneiform is extremely uncommon. This case study presents a 25-year-old male with a rare Lisfranc injury involving dorsal dislocation of the intermediate cuneiform and second metatarsal, following a motorcycle accident. Diagnosis was confirmed through radiographs and CT scans. The patient underwent closed reduction with percutaneous pinning and K-wire fixation. Postoperative outcomes were favourable, with the patient achieving full recovery and no residual pain. This report highlights the importance of accurate diagnosis and timely intervention to prevent long-term complications. The discussion includes a review of the Lisfranc joint anatomy, classification of injuries, and imaging techniques essential for proper evaluation. The case underscores the need for heightened clinical awareness and systematic imaging approaches in managing such rare injuries.

The Topographic Map of the Midfoot: Implication for Improving Safety of Dorsal Approach of Midfoot Surgeries

PURPOSE

The surgical approach for midfoot injuries classically requires dual dorsal incision and identification of the neurovascular structures that are susceptible to injury during the surgery. The aim of this study was to map the topographic anatomy of the dorsum of the foot along with tarsal joints for the dorsal approach of midfoot surgery that would facilitate the surgery and minimize the risk of neurovascular injuries for surgeons who specially focus on foot and ankle injuries.

METHODS

The dorsum of the foot was evaluated in 12 feet injected with latex containing a red colorant to visualize the arterial vessels. The navicular line, originating from the navicular tuberosity (NT) and passing over the dorsum of the foot, was used as a reference line. Dorsal foot neurovascular structures including cutaneous branches and muscles were mapped with respect to the tarsal joints and navicular line.

RESULTS

The deep peroneal nerve and dorsalis pedis artery were coursing between the base of the first and second metatarsal bones over which the tendon of the extensor hallucis brevis muscle was passing. The tendon of extensor hallucis brevis was crossing over the deep peroneal nerve and dorsalis pedis artery 55.2 mm superior and 45.0 mm lateral, respectively, from the NT.

CONCLUSION

This cadaver study supplies a detailed topographic map of the dorsum of the foot using the tarsal joints and NT as landmarks for protecting the neurovascular structures to facilitate midfoot surgeries for sports medicine surgeons who specially focus on foot and ankle injuries.

Primary arthrodesis versus open reduction internal fixation for acute Lisfranc injuries: a systematic review and meta-analysis

INTRODUCTION

The presence of a Lisfranc injury alone is considered a surgical indication in most patients. Indications for primary arthrodesis (PA) versus open reduction internal fixation (ORIF), however, is a topic of debate among surgeons. Conflicting data exists as to which treatment modality leads to improved patient-reported outcome measures (PROMs), reoperations, and complications.

METHODS

Databases queried included PubMed, OVID Medline, Embase, SCOPUS, Cochrane Central Register of Clinical Trials, and clinicaltrials.gov from their dates of inception to 3/21/2024. Studies were incorporated into this analysis if they had included patients with acute Lisfranc injuries and compared outcomes between PA and ORIF. PROMs, reoperations, and complications were captured. Results were reported as effect sizes (ES) and odds ratios (OR).

RESULTS

There were eighteen studies included in this SRMA. Pooled data from 13/16 studies that reported AOFAS and VAS demonstrated better outcomes after PA compared to ORIF. AOFAS was 84.4 ± 28.5 after PA and 75.7 ± 29.0 after ORIF. VAS pain was 1.4 ± 2.7 after PA and 2.0 ± 3.3 after ORIF. There were 3 more studies that reported other PROMs and favored ORIF. Return to preinjury activity was 79.2% after PA and 65.7% after ORIF. The prevalence of midfoot post-traumatic arthritis was reported as 2.8% after PA and 17.3% after ORIF. Adjacent joint arthritis was not reported in the current literature. After PA, 77/438 (17.6%) patients underwent reoperations, and after ORIF, 514/802 (64.1%) patients underwent reoperations. After excluding planned hardware removals, relative rates of unplanned reoperations were 14.7% (n = 62/423) after PA and 38.3% (n = 181/472) after ORIF (p < 0.001). Non-operative complications occurred in 43/406 (10.6%) patients after PA and 95/753 (12.6%) patients after ORIF (p = 0.31). Meta-analyses demonstrated that AOFAS (ES: 0.41, CI 0.13, 0.68, p = 0.004) and VAS pain (ES: - 0.53, CI - 0.91, - 0.15, p = 0.006), and return to activity rates (OR: 2.71, CI 1.43, 6.39) favored PA over ORIF. Post-traumatic arthritis (OR: 0.29, CI 0.11, 0.77) and reoperations (OR: 0.16, CI 0.06, 0.44) were less prevalent after PA compared to ORIF.

CONCLUSION

This systematic review and meta-analysis suggested that PA provides better short- and medium-term outcomes in the setting of Lisfranc injuries when compared to ORIF with rigid fixation. Due to a lack of available clinical studies, the long-term effects of PA are largely unknown but may include increased adjacent joint arthritis, pain, and need for further surgery-especially in young and active patients. Future research demonstrating long-term outcomes would be helpful in clinical decision making.

LEVEL OF EVIDENCE

I.

Ankle and Foot Injuries in the Emergency Department: Checklist-based Approach to Radiographs

A thorough understanding of the important anatomic landmarks and imaging features of the injury patterns of ankle and foot injuries aids radiologists in improving diagnostic accuracy in the emergency department.

Acute Lisfranc injury management

Lisfranc injuries were previously described as fracture-dislocations of the tarsometatarsal joints. With advancements in modern imaging, subtle Lisfranc injuries are now more frequently recognized, revealing that their true incidence is much higher than previously thought. Injury patterns can vary widely in severity and anatomy. Early diagnosis and treatment are essential to achieve good outcomes. The original classification systems were anatomy-based, and limited as tools for guiding treatment. The current review, using the best available evidence, instead introduces a stability-based classification system, with weightbearing radiographs and CT serving as key diagnostic tools. Stable injuries generally have good outcomes with nonoperative management, most reliably treated with immobilization and non-weightbearing for six weeks. Displaced or comminuted injuries require surgical intervention, with open reduction and internal fixation (ORIF) being the most common approach, with a consensus towards bridge plating. While ORIF generally achieves satisfactory results, its effectiveness can vary, particularly in high-energy injuries. Primary arthrodesis remains niche for the treatment of acute injuries, but may offer benefits such as lower rates of post-traumatic arthritis and hardware removal. Novel fixation techniques, including suture button fixation, aim to provide flexible stabilization, which theoretically could improve midfoot biomechanics and reduce complications. Early findings suggest promising functional outcomes, but further studies are required to validate this method compared with established techniques. Future research should focus on refining stability-based classification systems, validation of weightbearing CT, improving rehabilitation protocols, and optimizing surgical techniques for various injury patterns to ultimately enhance patient outcomes.

High risk and low incidence diseases: Lisfranc injury

INTRODUCTION

Lisfranc injuries are uncommon but frequently misdiagnosed and carry a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of Lisfranc injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

Lisfranc injuries are caused by high- or low-energy trauma to the tarsometatarsal (TMT) joint complex. The severity of injury exists on a spectrum, ranging from minor subluxations to fractures and dislocations involving the TMT joint complex. They can be complicated by compartment syndrome, neurovascular compromise, and open fractures. Prompt diagnosis is critical in preventing chronic pain and mobility challenges, as even small subluxations can result in significant morbidity. Lisfranc injuries should be considered in all patients with a foot injury. Patients with Lisfranc injuries most commonly present with midfoot pain, swelling, or ecchymosis. Despite the importance of a timely diagnosis, Lisfranc injuries are commonly missed on plain radiographs due to their often subtle findings. When x-rays are negative but there is significant clinical suspicion, emergency clinicians should obtain advanced imaging such as computed tomography to aid in diagnosis. All Lisfranc injuries should be discussed with orthopedic surgery to determine definitive management. Patients who can be discharged should be made non-weightbearing and placed in a short-leg splint.

CONCLUSION

The consideration of Lisfranc injuries can help emergency clinicians make a timely diagnosis to prevent future complications.

Effect of dorsoplantar miniscrew fixation of the second metatarsal base fracture on residual diastases in acute lisfranc fracture-dislocation

PURPOSE

This study aimed to evaluate and compare the clinico-radiographic outcomes between two techniques for acute Lisfranc fracture-dislocation with a large, displaced second metatarsal base plantar fracture: isolated Lisfranc screw fixation versus Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base.

METHODS

We retrospectively compared the clinico-radiographic outcome between patients who underwent isolated Lisfranc screw fixation (Group 1, 26 patients) and those who underwent Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base (Group 2, 23 patients). The main outcome measurements were the postoperative distance between the medial cuneiform and second metatarsal base on standing anteroposterior foot radiographs, known as the C1-M2 distance. Residual diastasis was defined as C1-M2 distance ≥ 2 mm on the affected side compared with that on the contralateral side. We also assessed the Foot and Ankle Ability Measure (FAAM)-activities of daily living (ADL) and sports subscale scores at three, six and ≥ 18 months postoperatively.

RESULTS

At the final follow-up, the mean C1-M2 distance on the affected side compared with that on the contralateral side was significantly greater in Group 1 than in Group 2 (3.9 versus 0.7 mm, P = 0.027). Furthermore, Group 1 showed a higher incidence of residual diastases at the final follow-up (69.2%) than the Group 2 (13.0%, P < 0.001). The FAAM-ADL scores at the final follow-up did not differ significantly between the groups (P = 0.518), but the FAAM Sports score was significantly higher in Group 2 than in Group 1 (P = 0.001).

CONCLUSIONS

The postoperative C1-M2 distance was better maintained with Lisfranc joint fixation with dorsoplantar miniscrew fixation of the second metatarsal base than with isolated Lisfranc screw fixation. We recommend that surgeons exercise caution when dealing with a second metatarsal plantar fracture and consider performing secure fixation using the dorsoplantar miniscrew technique for improved clinical outcomes.

The Mid- and Long-Term Consequences After Surgically Treated Lisfranc Injuries: A Case Series and Review of the Literature

Background Long-term follow-up data are difficult to collect, especially in uncommon foot injuries. Therefore, it is rare to find publications that include patient-reported outcomes. Therefore, a case series and systematic review are provided to evaluate mid- and long-term outcomes. Methods Patients operated for a Lisfranc injury in our hospital, between 2010 and 2016, were included. Patients were invited to fill out a combined European Foot and Ankle Score (EFAS) and Short Form (SF-12) questionnaire and to undergo an x-ray of the operated foot. In addition, a systematic review of the literature was performed, and our results were compared with that review. Results Fourteen out of 29 patients (48%, four male, 10 female) were seen at a mean follow-up of 8.3 years. Initial Hardcastle & Myerson Classification was: two A (14%); one B1 (7%); 10 B2 (71%); and one C2 (7%). Three patients underwent multiple surgeries: one external fixation followed by definitive stabilization, and two received fasciotomies (14%). The median EFAS score was 15.5, the EFAS sports score was 14, the SF-mental score was 55.73, and the SF-physical score was 48.25. There was substantial variability in outcomes between patients. 12 patients (86%) also underwent a follow-up X-ray exam, demonstrating a mean Kellgren-Lawrence score of 2.7. In the systematic review, 20 studies and 1052 feet with an average follow-up of 73 months met the inclusion criteria. Most cases underwent K-wire fixation (396 feet, 37.6%). Screw-only fixation was the next most common treatment (306 feet, 29.1%), followed by plate fixation (46 feet, 4.4%). Only three studies present primary arthrodesis in 68 (7.5%) cases. In 47 of the 686 patients (6.8%) with osteosynthesis (open reduction and internal fixation (ORIF)) a secondary definitive arthrodesis of the Lisfranc joint was required later. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 75. Conclusion Patients need to be informed about the possibility of limitations of activity, including sporting activity. Mid-term follow up studies are manly limited to ORIF. No operative technique shows an advantage in the mid-term.

Primary Arthrodesis or Open Reduction and Internal Fixation for Lisfranc Injuries: A Systematic Review and Meta-analysis of Randomized Controlled Trials

Background

Lisfranc injuries are often managed surgically with primary arthrodesis (PA) or open reduction and internal fixation (ORIF); however, neither approach has been shown to be superior. This systematic review and meta-analysis assessed randomized controlled trials (RCTs) to compare the functional and surgical outcomes of PA and ORIF in the treatment of Lisfranc injuries.

Methods

This study was performed as per the PRISMA protocol. Database searches were conducted on Cochrane, Embase, and PubMed libraries. Five RCTs were identified for inclusion involving 241 patients, of which 121 underwent PA and 120 underwent ORIF.

Results

Statistically significant differences in visual analog scale pain score at 2 years (mean difference 0.89, 95% CI 0.18-1.59), patient satisfaction (OR 10.04, 95% CI 1.78-56.76), and all-cause return to surgery (OR 27.31, 95% CI 12.72-58.63) were observed, all favoring PA. There were no statistically significant differences between PA and ORIF with regard to American Orthopaedic Foot & Ankle Society midfoot scores at 2 years, 36-Item Short Form Health Survey (SF-36) scores, and unplanned return to surgery.

Conclusion

This study showed significant improvement in pain at 2 years, patient satisfaction, and all-cause return to surgery favoring PA in all instances. Given ORIF often necessitates a second operation for hardware removal, it is to be expected that all-cause return to surgery is higher in ORIF groups. Overall, these results do not have the power to confer an advantage to a particular approach because of significant heterogeneity. Further studies should focus on larger patient cohorts and longer follow-up, or analysis stratified by patient demographics and injury presentation. In the absence of clinically significant differences, cost-benefit analyses should be considered to answer the question of whether to "fix or fuse" for Lisfranc injuries.

Cone-beam computed tomography imaging and three-dimensional analysis of midfoot joints during non-weightbearing and weightbearing in 11 healthy feet

BACKGROUND

Studies report that Lisfranc injury is more common than thought. Several imaging methods for assessing the stability of Lisfranc injury have been described but many are impossible to standardize and not accurate enough.

PURPOSE

To present a three-dimensional (3D) method for analyzing the changes in the joint space width of the midfoot joint and the joints of the medial part of the Lisfranc complex in healthy individuals.

MATERIAL AND METHODS

Non-weightbearing and weightbearing cone-beam computed tomography (CBCT) images of 11 healthy feet were acquired and analyzed with 3D software. The mean range of joint space width changes of each joint was computed from the changes in individual image pairs.

RESULTS

3D analysis software was used to analyze the medial part of the Lisfranc complex. In this sample of healthy feet, the changes in the joint spaces in the medial part of Lisfranc complex, calculated with 3D analysis software, was less than 0.6 mm. The distance between bones increased or decreased, depending on which part of the joint surface the measurements were taken.

CONCLUSION

In this study, we present a 3D analysis method to evaluate midfoot joint space width changes. Our analysis revealed that in healthy feet there are only minimal changes in the joint space width between weightbearing and non-weightbearing indicating minimal movement of the midtarsal joints. The 3D analysis of weightbearing CBCT data provides a promising tool for analyzing the small midfoot joints in a variety of conditions.

Internal Brace Fixation Technique for Lisfranc Injury: A Retrospective Study

BACKGROUND The Lisfranc ligament is crucial for maintaining the transverse and longitudinal arch of the foot. Owing to the disruption between the medial cuneiform bone and the base of the second metatarsal bone, the currently preferred fixation method remains controversial. Our fixation technique involves screwing one anchor to the medial and intermediate cuneiform bones and using the anchor to carry the ligament to bind the Lisfranc joint and first and second metatarsal joints altogether for elastic fixation. This study evaluated the clinical and functional outcomes of InternalBrace fixation for Lisfranc injury. MATERIAL AND METHODS This retrospective study included 58 patients who underwent InternalBrace fixation for Lisfranc injury between January 2019 and September 2022 by an experienced surgeon. One-way analysis of variance or t test was used. Preoperative classification was performed according to the Myerson classification with imaging data. Postoperative follow-up was performed based on intraoperative blood loss, fracture healing time, visual analog scale (VAS) score, the American Orthopedic Foot and Ankle Society (AOFAS) score, Tegner score, and complications. RESULTS Surgery was completed in all patients, and follow-up was performed. The patients' ages ranged from 19 to 62 years (average: 34.6±9.4 years). The postoperative follow-up time was 12-24 months (average: 16.9±3.0 months). The average time for fracture healing was 12.8±3.0 (10-24) weeks. The VAS, AOFAS, and Tegner scores significantly improved postoperatively (from 5.33±1.0 (3-7) to 1.24±0.57 (0-2); 28.02±6.70 (18-51) to 91.59±4.76 (82-96); and 2.40±0.67 (1-4) to 6.53±0.54 (6-7), respectively), which was statistically significant (P<0.01), and the good rate of AOFAS was 91.4%. The postoperative complications were traumatic arthritis, incision infection, and temporary dorsal foot numbness, which gradually recovered. No other rejection reactions or Lisfranc fracture/dislocations recurrence occurred during the follow-up period. CONCLUSIONS InternalBrace fixation for Lisfranc injury is beneficial for restoring Lisfranc joint stability and function and allows for early and more aggressive rehabilitation for patients, with fewer surgical complications.

Serious injuries of Lisfranc joint: A retrospective multicenter study of 141 patients

INTRODUCTION

Lisfranc joint injuries are common and often underdiagnosed. They occur during trauma of various mechanisms, high or low energy. Their management is difficult because of the wide spectrum of lesions and the management of associated lesions, particularly in the emergency stage. Their surgical treatment remains controversial. Therefore, the objective of this study was to evaluate and compare the management of Lisfranc injuries and to study their clinical, functional and radiologic evolution. We also wanted to assess the consequences of these lesions on the patient's quality of life.

MATERIAL AND METHODS

This was a retrospective multicenter study of 141 patients over 16 years at the time of the trauma. The patients included had presented a Lisfranc injury from January 2010 to June 2018. The epidemiological characteristics, the type of osteosynthesis, and the immediate and radiographic results at the last follow-up were collected. Functional assessment was analyzed by telephone review using the SF12, FAAM and AOFAS scores.

RESULTS

An associated M2 base fracture was found in almost 50 % of cases. A closed reduction and fixation was made in 25 % of cases. There was 69 % pins fixation. The reduction was not anatomical in 1/3 of the cases and was more difficult to achieve with an associated fracture. The FAAM score was statistically superior in the patients with internal fixation by screws compared to the treatment by pins. We found 18 % early complications. At least 1 year after the injury, C2M2 osteoarthritis was found in 45 % of patients.

DISCUSSION

Contrary to what is recommended in the literature, this study reported a high rate of osteosynthesis by pins whereas screws and plates were more recommended. Open reduction was also recommended and was the strategy of choice in this study. An M2 fracture was often associated with Lisfranc dislocations. The quality of reduction was essential and was better with open reduction and screw fixation.

Factors Influencing PROMIS Scores and Patient Reported Outcomes Following Surgical Intervention of Isolated Lisfranc Injury: Minimum 2 Year Follow-up

Lisfranc injuries are rare but significant foot injuries, as they often result from polytrauma patients, and are often misdiagnosed, which further complicate their evaluation and contribute to their propensity towards disability. It is recommended that, on diagnosis, Lisfranc injuries be treated as soon as possible to decrease the risk of future chronic pain, disability, or osteoarthritis. Our study evaluated patients who completed the patient reported outcome measurement information systems (PROMIS) along with the foot function index (FFI) following operative fixation for Lisfranc injury. Fifty-one patients between 2010 and 2020 met inclusion criteria and were selected for this study, with completion. Utilizing the electronic medical record (EMR), patient charts were reviewed to obtain basic patient demographic information and comorbidities. Operative reports were reviewed to determine which procedure was performed for definitive fixation. Primary arthrodesis was associated with a significant decrease in complication rates (p = .025) when compared to ORIF. Females, arthrodesis, and procedures using a home run (HR) screw were independent risk factors for significantly higher reports of PROMIS pain interference. Arthrodesis also was associated with lower PROMIS pain interference scores. Arthrodesis and males exhibited higher scores in all FFI categories. Our results provide evidence that patient reported outcomes following Lisfranc surgery reported via PROMIS, FFI and VAS scores are independently influenced by patient demographics, comorbidities, and surgical variables. Analysis of potential associations between these patient characteristics and PROMIS and FFI scores provides evidence for physicians to manage patient expectations prior to operative treatment of a nonpolytraumatic Lisfranc injury.

Effective Rehabilitation of a Lisfranc Fracture in a 25-Year-Old Male Patient: A Case Report

A dislocation or break of the tarsometatarsal joint in the foot is referred to as a Lisfranc fracture, sometimes called a Lisfranc injury. It can be caused by less stressful mechanisms like a twisting fall as well as high-energy events like car crashes or falls from heights. Swelling, bruises, and midfoot pain that gets worse when standing or walking are some of the symptoms. The damage may only affect the ligaments or the foot's bony structures. Nonoperative or surgical treatment may be part of the management, depending on how severe the injury is. In order to realign and stabilize the bones, open reduction internal fixation with Kirschner wires (K-wires) is a common surgical procedure. In this case, a 25-year-old male patient complained of left foot pain and wound. He gave a history of a left leg stuck in the harvester. Immediately, he was taken to a local hospital, where a dressing of his left foot was done. He was referred to a super specialty hospital where an investigation, like an X-ray, was done, which revealed a Lisfranc fracture. K-wire was applied to fix the Lisfranc fracture. Further on, rehabilitation was started to restore mobility, regain full range of motion, and develop muscle strength. American Orthopedic Foot and Ankle Score (AOFAS) and Lower Extremity Functional Scale (LEFS) were used as outcome measures.

Nonunion Rate Following Primary Arthrodesis for Acute Lisfranc Injuries

Injury to the tarsometatarsal joint (TMT) results in instability throughout the midfoot that does not often improve with conservative management. If instability is identified, surgical intervention is frequently recommended, either open reduction and internal fixation (ORIF) or primary arthrodesis (PA). These 2 treatment options have been compared in the literature multiple times, often reporting similar outcomes. Due to this, as well as the need for subsequent hardware removal after ORIF has led many surgeons towards PA at the index surgery. Concern for nonunion is a leading concern with surgeons who advocate instead for ORIF. The purpose of this study is to review patients who underwent PA and observe nonunion rates. Nonunion at the TMT has been previously studied, but only in the chronic setting. We performed a retrospective study of 34 patients who had PA in the management of an acute Lisfranc injury. The average age in our study was 43.9 years old (range 19-72, SD 17.4) with an average follow-up of 9.4 months (range 4-33, SD 6.2). Radiographs were evaluated for signs of nonunion at regular postoperative intervals. Within the patients included in the study, a total of 71 TMT joints were fused. Overall successful fusion rate was 95.8% at an average of 7.9 weeks (range 6-12, SD 1.4) postoperatively. Individual nonunion rates at the first, second, and third TMT were 0%, 1.4% and 2.8% respectively. Our study demonstrates that primary arthrodesis provides a predictable outcome with low nonunion rates in the management of acute Lisfranc injury.

Comparison of 4 Different Fixation Strategies for Midfoot Arthrodesis: A Retrospective Comparative Study

BACKGROUND

Midfoot arthrodesis is a common procedure performed both for arthritis and correction of deformity. The optimal fixation for midfoot arthrodesis has not been established, though numerous studies have been investigating the fixation techniques of midfoot arthrodesis. The purpose of this study was to compare the union rate of midfoot arthrodesis using 4 different fixation strategies and investigate risk factors of nonunion following midfoot arthrodesis.

METHODS

A retrospective chart review was performed for patients who underwent midfoot joint arthrodesis between January 2014 and May 2019. The rates of nonunion and postoperative complication were compared among 4 different fixation constructs: staple fixation, compression plate fixation, compression plate with lag screw fixation, and compression screw fixation. Predictors of nonunion following midfoot arthrodesis were investigated through a multivariable logistic regression analysis. A total of 95 patients (99 feet), including 240 midfoot joints were included in this study. The mean follow-up period was 78.4 weeks.

RESULTS

Overall, bony union was achieved in 86 out of 99 (86.9%) patients, which included 218 out of 240 (90.8%) midfoot joints. A significant difference in the nonunion rate according to the type of fixation construct was found (P = .011); the compression screw alone fixation construct was noted to have a significantly higher nonunion rate than other fixation constructs. Diabetes mellitus (odds ratio [OR] = 0.179 [95% CI: 0.059, 0.542]), the type of fixation construct (compression screw alone; OR =1.789 [95% CI: 1.071, 2.978]), lack of adjuvant bone graft (OR = 2.803 [95% CI: 1.081, 7.268], and postoperative nonanatomical alignment (OR = 3.937 [95% CI: 1.278, 12.126]) were identified as independent predictors of nonunion following midfoot arthrodesis.

CONCLUSION

The rate of nonunion following midfoot arthrodesis among 4 different commonly used fixation constructs was compared in this study. Risk factors of nonunion were investigated revealing that diabetes mellitus, compression screw fixation alone, lack of adjuvant bone graft, and postoperative nonanatomical alignment are independent predictors of nonunion following midfoot arthrodesis.

LEVELS OF EVIDENCE

Level III: Comparative cohort study.

Multidisciplinary Management and Rehabilitation of Severe Crush Injury Resulting in Lisfranc Fracture: A Case Report

A 58-year-old male patient was seriously injured in his left foot as a result of a passenger car accident, resulting in a Lisfranc fracture and complications on his left side. The initial injury resulted in a 20-cm laceration, severe pain, and severe swelling. After primary care at the government hospital, the patient was referred to Acharya Vinoba Bhave Rural Hospital (AVBRH) for further treatment. Clinical examination revealed infection, Lisfranc ligament rupture, bone exposure, restriction of movement, and muscle strength. His fracture was managed with Kirschner wire(K-wire) fixation surgically. A holistic physical management plan includes immobilization and a comprehensive medical program to reduce edema, muscle atrophy, and joint stiffness. Post physiotherapy showed significant improvements in joint function, muscle strength, and functional scores after rehabilitation. Outcome measures such as the Lower Extremity Functional Scale, Olerud-Molander Ankle Score, and Patient-Reported Outcomes Measurement Information System-29 are related to physical recovery, stress reduction, and healing as a whole-life treatment. These data highlight the importance of a collaborative, multidisciplinary approach in the effective management of Lisfranc fracture injuries and confirm the advantages of timely intervention and physical therapy for the benefit of these patients.

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

IMPORTANCE

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

OBJECTIVES

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

EVIDENCE REVIEW

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

FINDINGS

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

CONCLUSIONS AND RELEVANCE

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

LEVEL OF EVIDENCE

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

Inconsistent radiographic diagnostic criteria for lisfranc injuries: a systematic review

PURPOSE

To evaluate the radiographic diagnostic criteria and propose standardised radiographic criteria for Lisfranc injuries.

METHODS

A systematic review of the PubMed and Embase databases was performed according to the PRISMA guidelines. The various radiographic criteria for the diagnosis of Lisfranc injuries were extracted. Descriptive statistics were presented for all continuous (as mean ± standard deviation) and categorical variables (as frequencies by percentages).

RESULTS

The literature search included 29 studies that totalled 1115 Lisfranc injuries. The risk of bias ranged from "Low" to "Moderate" risk according to the ROBINS-I tool. The overall recommendations according to the GRADE assessment ranged from "Very Low" to "High". 1st metatarsal to 2nd metatarsal diastasis was the most common of the 12 various radiographic diagnostic criteria observed, as was employed in 18 studies. This was followed by 2nd cuneiform to 2nd metatarsal subluxation, as was employed in 11 studies.

CONCLUSION

The radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. The proposition for homogenous radiographic diagnostic criteria is that the following features must be observed for the diagnosis of Lisfranc injuries: 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. Further advanced imaging by CT or MRI may be required in patients with normal radiographs but with continued suspicion for Lisfranc injuries.

LEVEL OF EVIDENCE

4, systematic review.

Lisfranc Sports Injuries: What Do We Know So Far?

Lisfranc sports injuries include tarsometatarsal joint injuries, which may be accompanied by fractures. They most commonly occur due to a blow or axial force. The aim of this review is to assess the current standards for surgical intervention in Lisfranc injuries resulting from sports-related accidents. This evaluation will cover the timing of treatment, the recovery process, and the appropriate timing for a return to normal sporting activities. This research was done via an analytical review of current literature. Methods included a structured search strategy on PubMed, Science Direct, and Google Scholar. The collated literature was processed using formal inclusion or exclusion, data extraction, and validity assessment. Joint involvement and severity were taken into account while classifying Lisfranc injuries. The primary fixation and fusion techniques for Lisfranc injuries were compared, and the surgical management of these injuries was examined in all of the literature. Treatment recovery times were examined, and the results were talked about. A variety of injuries, from minor sprains to serious fractures and rips, make up Lisfranc injuries. Although open reduction internal fixation (ORIF) in combination with primary arthrodesis (PA) is now thought to be the optimum course of treatment, its acceptance has increased. Patients with Lisfranc injuries can usually expect excellent outcomes and the return of joint function to its pre-injury form if the injury is appropriately assessed and treated. Lisfranc injuries are manageable and have a good recovery time if not neglected. The outcomes of management and surgical options are also quite satisfactory.

Outcomes of Surgically Treated Purely Ligamentous Stage II Lisfranc Injuries

BACKGROUND

Low-energy stage II Lisfranc injuries are rare, and treatment can be operative or nonoperative based on a surgeon's assessment of midfoot stability. No previously published patient-reported outcome measures (PROMs) data for Lisfranc injuries isolates purely ligamentous stage II injuries. The purpose of this study was to analyze PROMs for patients who underwent operative management of stage II Lisfranc injuries.

METHODS

Thirty-nine patients (39 feet) with confirmed Nunley-Vertullo stage II Lisfranc injuries between May 2012 and February 2022 were identified through a retrospective chart review. PROMs that were analyzed were the visual analog scale (VAS) pain scale, Veterans RAND 12-Item Health Survey (VR-12), Foot and Ankle Ability Measure (FAAM), and patient satisfaction.

RESULTS

Thirty-two open reduction internal fixations (ORIFs) and 7 fusions were performed. The mean latest follow-up was 44.6 (range, 12-92) months. There were 2 complications (5%, 2/39) that required a revision procedure. Twenty-six patients (67%, 26/39) underwent secondary surgery to remove retained hardware. The mean time to hardware removal was 3.97 (range, 2.70-7.47) months. The overall mean patient satisfaction score with overall medical care including clinical visits and interactions with medical staff personnel was 93.6/100. All PROMs (VAS, VR-12, FAAM) demonstrated statistically significant improvement (P < .05) from preoperative (injury) values to latest follow-up postinjury values.

CONCLUSION

Patients who were treated surgically with stage II purely ligamentous Lisfranc injuries via the methods used were found to mostly undergo hardware removal and have high levels of overall satisfaction with their process of medical care.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Lisfranc Injury Diagnosis: What Is the Diagnostic Reliability of New Radiographic Signs Using Three-dimensional CT?

BACKGROUND

Up to one-third of Lisfranc injuries (an injury affecting the normal stability, alignment, and congruency of the tarsometatarsal joints) are misdiagnosed. Delayed diagnosis and improper treatment may lead to long-term, irreversible sequela and functional disability. Recently, the employment of three-dimensional (3D) CT demonstrated higher diagnostic reliability, but there is limited evidence on this, and radiologic features of Lisfranc injuries when using this diagnostic modality are not well described.

QUESTION/PURPOSE

What is the diagnostic performance of several novel radiographic signs on 3D CT when evaluating for Lisfranc injury, namely the Mercedes sign, the peeking metatarsal sign, and the peeking cuneiform sign, and what is the interobserver and intraobserver reliability of those diagnostic signs?

METHODS

In this retrospective, diagnostic study, video clips of 3D CT reconstructions of 52 feet with intraoperatively confirmed Lisfranc injuries and 50 asymptomatic feet with a normal appearance of the tarsometatarsal joints, as ascertained by a subspecialty-trained foot and ankle surgeon and a musculoskeletal radiologist, were analyzed by two foot and ankle specialists and three orthopaedic residents twice each, with a washout period of 2 weeks. Among the 52 patients with intraoperative evidence of Lisfranc injury, there were 27 male patients and 25 female patients, with a median (IQR) age of 40 years (23 to 58); among the 50 controls, there were 36 male and 14 female patients, with a median age of 38 years (IQR 33 to 49). For each video clip, the presence of all three radiographic signs was documented (each sign was rated in a binary yes/no fashion). Before the evaluations, all observers underwent a short training session by the head of the foot and ankle department. Later, these reading were used to assess for the sensitivity, specificity, and area under the receiver operating characteristic curve in terms of Lisfranc diagnosis against the gold standard of intraoperative testing of tarsometatarsal joint stability. Intraoperatively, the congruency and stability of the second tarsometatarsal joint had been evaluated by direct visualization and by the insertion of a probe into the joint between the base of the second metatarsus and the medial cuneiform and twisting the probe to assess for stability. The individuals evaluating the video clips were unaware of the surgically obtained diagnosis at the time they performed their evaluations.

RESULTS

All 3D radiographic signs that were examined had excellent diagnostic reliability in terms of sensitivity and specificity, ranging from 92% to 97% and from 92% to 93%, respectively. When assessing the association between the suggested 3D radiographic signs and Lisfranc injury diagnosis as a function of the area under the receiver operating characteristic curve, the Mercedes sign demonstrated a higher area under the curve than the other signs did (0.91 versus 0.87 versus 0.8; p < 0.001). The mean intraobserver and interobserver reliability (kappa) values were excellent for all 3D radiographic signs that were evaluated.

CONCLUSION

The proposed radiographic findings demonstrated excellent diagnostic performance and were repeatable within and among observers. Three-dimensional CT radiographic signs could function as a valuable diagnostic tool for the evaluation and initial screening for Lisfranc injury in the acute injury phase because obtaining AP bilateral standing radiographs of the foot is often impractical in the acute setting. Further research and comparison with AP weightbearing radiographs of the bilateral feet may be warranted.

LEVEL OF EVIDENCE

Level III, diagnostic study.

The feasibility study of stress position device simulating standing weight-bearing applied in computed tomography examination

BACKGROUND

In order to simulate weight-bearing Computed Tomography (CT) examination, this study designed a simple stress position device. By analyzing the relevant data of stress position footprints and weight-bearing position footprints, the feasibility of the stress position device to simulate standing weight-bearing was verified.

METHODS

This study randomly selected 25 volunteers for standing weight-bearing and stress position footprints collection, and measured the relevant indicators of stress position footprints and standing weight-bearing position footprints. Two foot and ankle surgeons conducted two measurements respectively on the footprints. Intra-observer and inter-observer reliability were calculated using intra-class correlation coefficients (ICC). Pearson correlation coefficient, ICC, scatter plot analysis, and paired t-test were used to analyze the stress and weight-bearing position data.

RESULTS

The intra-observer and inter-observer measurement values were reliable. There was a certain degree of correlation between the stress position footprints and weight-bearing position footprints in terms of Pearson correlation coefficient, ICC, and scatter plot analysis. Paired t-tests showed significant differences in Clarke angle (t 2.636, p .012), C-S index (t 10.568, p .000), arch indx (t 2.176, p .035), and arch lower angle (t 6.246, p .000).

CONCLUSION

The stress position device can generate a certain degree of stress, and after further optimization and improvement of the stress position device, it is feasible to apply it to weight-bearing CT examination in clinical settings.

Lisfranc Injury: Recent Trends in Management

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

Various Flexible Fixation Techniques Using Suture Button for Ligamentous Lisfranc Injuries: A Review of Surgical Options

Contrary to Lisfranc joint fracture-dislocation, ligamentous Lisfranc injury can lead to additional instability and arthritis and is difficult to diagnose. Appropriate procedure selection is necessary for a better prognosis. Several surgical methods have recently been introduced. Here, we present three distinct surgical techniques for treating ligamentous Lisfranc employing flexible fixation. First is the "Single Tightrope procedure", which involves reduction and fixation between the second metatarsal base and the medial cuneiform via making a bone tunnel and inserting Tightrope. Second is the "Dual Tightrope Technique", which is similar to the "Single Tightrope technique", with additional fixation of an intercuneiform joint using one MiniLok Quick Anchor Plus. Last but not least, the "internal brace approach" uses the SwiveLock anchor, particularly when intercueniform instability is seen. Each approach has its own advantages and disadvantages in terms of surgical complexity and stability. These flexible fixation methods, on the other hand, are more physiologic and have the potential to lessen the difficulties that have been linked to the use of conventional screws in the past.

Six-Week Old Neglected Homolateral Lisfranc Injury - A Case Report

Introduction

Lisfranc injury is relatively rare and is commonly missed at the initial presentation as these injuries are easily misdiagnosed as a foot sprain. We report a case of chronic foot pain following an injury which was later diagnosed to be a neglected 6 weeks old complex Lisfranc fracture dislocation.

Case Report

A 53-year-old man presented with chronic foot pain and swelling which was diagnosed to be a neglected 6-week-old homolateral type of Lisfranc injury (type A Hard castle and Meyerson). We treated him with open reduction and internal fixation (ORIF) with plates and screws and achieved excellent functional outcome at 6-month follow-up period.

Discussion

Lisfranc injuries are frequently undetected with estimates ranging from 20% to 80%. Anteroposterior, lateral, and medial oblique views of the foot should be included in the radiological workup following a thorough physical examination. Our case will aid the deficient literature and guide the young surgeons in management of such cases.

Conclusion

Given the history and nature of the injury, it can be easily missed by a beginner and the clinician must keep a high index of suspicion when treating these injuries in emergency department. To prevent the many complications linked to this kind of injury, it requires a correct diagnosis and timely treatment in the form of closed/open reduction and fixation. Delayed presentation of such cases can be treated with ORIF and good functional outcome can be achieved.

Morphologic analysis of the 1st and 2nd tarsometatarsal joint articular surfaces

Tarsometatarsal joint arthrodesis is used to treat a variety of injuries and deformities in the midfoot. However, the surgical technique has not been optimized, in part due to limited knowledge of morphologic features and variation in the related joints. Previous research has relied primarily on dissection-based anatomical analysis, but quantitative imaging may allow for a more sophisticated description of this complex. Here, we used quantitative micro-CT imaging to examine dimensions, distance maps, and curvature of the four articular surfaces in the first and second tarsometatarsal joints. Image segmentation, articular surface identification, and anatomic coordinate systems were all done with semi or fully automatic methods, and distance and size measurements were all taken utilizing these anatomic planes. Surface curvature was studied using Gaussian curvature and a newly defined measure of curvature similarity on the whole joint and on four subregions of each surface. These data show larger articular surfaces on the cuneiforms, rather than metatarsals, and define the generally tall and narrow articular surfaces seen in these joints. Curvature analysis shows minimally curved opposing convex surfaces. Our results are valuable for furthering knowledge of surgical anatomy in this poorly understood region of the foot.

Nonoperative management of lisfranc injuries - A systematic review of outcomes

BACKGROUND

Historically, most Lisfranc injuries have been considered to be unstable and treated with surgical intervention. However, with better access to cross-sectional imaging, stable injury patterns are starting to be recognised. The aims of the current study were to perform a systematic review of outcomes of Lisfranc injuries treated non-operatively.

METHODS

A literature review was performed of studies reporting nonoperative management of Lisfranc injuries (PROSPERO registered and following PRISMA guidelines). Following exclusions, 8 papers were identified: 1 prospective and 7 retrospective studies. A total of 220 patients were studied with a mean age of 39.8 years and a mean follow-up of 4.3 years. Outcomes included function, displacement, and rates of surgery.

RESULTS

High heterogeneity was observed with variable outcomes. Four papers reported good outcomes, with adjusted functional scores ranging from 82.6 to 100 (out of 100). However, one study reported late displacement in 54 % of patients. Rates of secondary osteoarthritis ranged from 5 % to 38 %. Rates of surgical intervention were as high as 56 %. Several studies compared operative to non-operative treatment, reporting superior outcomes with surgery. Those injuries with no displacement on CT, measured at the medial cuneiform-second metatarsal had the best outcomes.

CONCLUSION

Reported outcomes following nonoperative treatment of Lisfranc injuries vary widely, including high rates of conversion to surgery. In contrast, some studies have reported excellent functional outcomes. CT seems to be an important diagnostic tool in defining a stable injury. Due to limited data and lack of a clear definition of a stable injury or treatment protocol, prospective research is needed to determine which Lisfranc injuries can be safely treated nonoperatively.

Is the diagnostic validity of conventional radiography for Lisfranc injury acceptable?

BACKGROUND

Lisfranc injuries mainly involve the tarsometatarsal joint complex and are commonly misdiagnosed or missed in clinical settings. Most medical institutions prefer to use conventional radiography. However, existing studies on conventional radiographs in Lisfranc injury lack a large population-based sample, influencing the validity of the results. We aimed to determine the diagnostic validity and reliability of conventional radiography for Lisfranc injury and whether computed tomography can alter clinical decision-making.

METHODS

This retrospective study included 307 patients with, and 100 patients without, Lisfranc injury from January 2017 to December 2019. Diagnosis was confirmed using computed tomography. A senior and junior surgeon independently completed two assessments of the same set of anonymised conventional radiographs at least 3 months apart. The surgeons were then asked to suggest one of two treatment options (surgery or conservative treatment) for each case based on the radiographs and subsequently on the CT images.

RESULTS

All inter- and intra-observer reliabilities were moderate to very good (all κ coefficients > 0.4). The mean (range) true positive rate was 81.8% (73.9%-87.0%), true negative rate was 90.0% (85.0%-94.0%), false positive rate was 10.0% (6.0%-15.0%), false negative rate was 18.2% (13.0%-26.1%), positive predictive value was 96.1% (93.8%-97.8%), negative predictive value was 62.4% (51.5%-69.7%), classification accuracy was 83.8% (76.7%-88.2%), and balanced error rate was 14.1% (10.2%-20.5%). Three-column injuries were most likely to be recognized (mean rate, 92.1%), followed by intermediate-lateral-column injuries (mean rate, 81.5%). Medial-column injuries were relatively difficult to identify (mean rate, 60.7%). The diagnostic rate for non-displaced injuries (mean rate, 76.7%) was lower than that for displaced injuries (mean rate, 95.5%). The typical examples are given. A significant difference between the two surgeons was found in the recognition rate of non-displaced injuries (p = 0.005). The mean alteration rate was 21.9%; the senior surgeon tended to a lower rate (15.6%) than the junior one (28.3%) (p < 0.001).

CONCLUSIONS

The sensitivity, specificity, and classification accuracy of conventional radiographs for Lisfranc injury were 81.8%, 90.0%, and 83.8%, respectively. Three-column or displaced injuries were most likely to be recognized. The possibility of changing the initial treatment decision after subsequently evaluating computed tomography images was 21.9%. The diagnostic and clinical decision-making of surgeons with different experience levels demonstrated some degree of variability. Protected weight-bearing and a further CT scan should be considered if a Lisfranc injury is suspected and conventional radiography is negative.

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

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

Does temporary bridge plate fixation preserve joint motion after an unstable Lisfranc injury?

BACKGROUND

Recently, temporary bridge plate fixation has gained popularity in the treatment of unstable Lisfranc injuries. The technique aims to reduce the risk of posttraumatic osteoarthritis, and after plate removal, the goal is to regain joint mobility. Here we explore marker-based radiostereometric analysis (RSA) to measure motion in the 1st tarsometatarsal (TMT) joint and asses the radiological outcome in patients treated with this surgical technique.

METHOD

Ten patients with an unstable Lisfranc injury were included. All were treated with a dorsal bridge plate over the 1st TMT joint and primary arthrodesis of the 2nd and 3rd TMT joints. The plate was removed four months postoperatively. Non- and weight-bearing RSA images were obtained one and five years postinjury to assess joint mobility and signs of osteoarthritis.

RESULTS

Detectable 1st TMT joint motion was observed in 2/10 patients after one year, and 6/9 patients after five years. At the final follow-up, mean 1st TMT dorsiflexion was 2.0°. Radiologically, the incidence of posttraumatic osteoarthritis was present in 4/10 patients after one year, and 5/9 patients after five years. All patients had observed TMT joint stability throughout the follow-up period.

CONCLUSION

Preservation of joint motion can be achieved with a temporary bridge plate fixation over the 1st TMT joint.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prospective cohort study/Therapeutically level IV.

Closed Reduction and Percutaneous Fixation of Lisfranc Injury Using Suspensory Fixation

Background

This closed reduction and percutaneous fixation (CRPF) technique utilizing suspensory fixation is indicated for the treatment of Lisfranc injuries with displacement or instability of the tarsometatarsal joint complex-and typically only for low-energy, purely ligamentous Lisfranc injuries. The goal of this procedure is to restore joint stability and prevent common complications of Lisfranc injuries (e.g., midfoot arch collapse and posttraumatic arthritis) while avoiding the complications and risks associated with open reduction and internal fixation (ORIF) and primary arthrodesis. We recommend performing the procedure within 10 to 14 days of the injury; otherwise, an open debridement may be necessary to address scar tissue formation.

Description

We start with the patient in the supine position and perform a fluoroscopic stress examination of the joint. Next, the Lisfranc joint undergoes closed reduction, which is held in place with a clamp. Following reduction, a guidewire is drilled from the lateral border of the base of the 2nd metatarsal medially through the medial cuneiform, followed by a medial-to-lateral cannulated drill. The suspensory fixation is then passed lateral-to-medial, placing the suture button on the lateral cortex of the 2nd metatarsal base. The tape is then tensioned while a bioabsorbable interference screw is inserted to maintain tension.

Alternatives

Prior studies have assessed both operative and nonoperative alternatives to CRPF with suspensory fixation for the treatment of Lisfranc injuries. Nonoperative treatment with closed reduction and cast immobilization of Lisfranc injuries is typically reserved for nondisplaced injuries; however, a number of studies have shown poor outcomes with use of this technique1-3. The 2 most common operative alternatives are ORIF and primary arthrodesis4.

Rationale

CRPF with suspensory fixation offers several benefits over both traditional surgical techniques such as ORIF and primary arthrodesis, as well as over percutaneous reduction and internal fixation (PRIF) with a screw. Compared with ORIF and primary arthrodesis, a number of studies have shown that percutaneous treatment of Lisfranc injuries minimizes soft-tissue trauma and reduces the risk of postoperative complications such as wound breakdown, infection, and complex regional pain syndrome, while allowing for earlier participation in rehabilitation5-10. A systematic review of outcomes following PRIF with screw fixation also showed that percutaneous treatment of Lisfranc injuries is a safe and effective technique with good functional outcomes11. When comparing PRIF with a screw to our technique of CRPF with suspensory fixation, CRPF has the added benefit of creating a nonrigid fixation in the Lisfranc joint, which allows for increased range of motion of the medial column and improved return to activity12,13. The rigid fixation in PRIF with a screw can also lead to metal irritation, intra-articular screw fracture, and impaired mobility, which often necessitate the need for screw removal13-15. This fixation-related drawback is not present with our technique, and also avoids the need for use of a biologic substitute such as tendon grafts13.

Expected Outcomes

Following CRPF with suspensory fixation, patients can expect to return to full activity at 12 to 16 weeks postoperatively. Postoperatively, patients are typically kept non-weight-bearing for 6 weeks. The operative foot is kept immobilized in a splint for the first 2 weeks, then transitioned to a boot. Between postoperative weeks 6 and 12, partial progressive weight-bearing is introduced with use of an arch support, progressing toward full weight-bearing13,16,17.For comparison, patients who underwent PRIF with screw fixation had a similar postoperative course, but almost all required screw removal at 4 to 6 months postoperatively13,16. Cho et al. retrospectively reviewed the results of 63 patients who underwent either PRIF with screw fixation (n = 32) or CRPF with a suture button (n = 31) and found that CRPF patients had significantly better American Orthopaedic Foot & Ankle Society midfoot scale scores (81 versus 74 points) and visual analog scale scores (3.1 versus 4.6 points) at 6 months postoperatively and prior to screw removal in the PRIF group (p < 0.001). There were no significant differences in these scores, radiographic outcomes, weight-bearing analysis, or complications at 1 year postoperatively. The authors concluded that both techniques provided comparable fixation stability and clinical outcomes. Of note, however, the PRIF group had 4 patients whose postoperative course was complicated by screw breakage13.

Important Tips

Start with a fluoroscopic stress examination to identify all components of instability.Ensure that the reduction clamp does not interfere with or affect your guidewire path.If the joint cannot be reduced, convert to an open procedure and debride the obstruction.

Acronyms and Abbreviations

ORIF = open reduction and internal fixationPRIF = percutaneous reduction and internal fixationCRPF = closed reduction and percutaneous fixationNSAID = nonsteroidal anti-inflammatory drugOR = operating roomAP = anteroposteriorCT = computed tomographyMRI = magnetic resonance imagingAOFAS = American Orthopaedic Foot & Ankle SocietyVAS = visual analog scaleROM = range of motionPT = physical therapyASA = acetyl-salicylic acid (aspirin)BID = twice dailyPRN = as needed.

Functional Outcomes of Dorsal Bridge Plating for Lisfranc Injuries With Routine Implant Retention: A Major Trauma Center Experience

OBJECTIVES

To assess medium-term functional outcomes and the complication profile for unstable Lisfranc injuries treated with dorsal bridge plate (DBP) fixation when implants are not routinely removed.

DESIGN

Large single-center retrospective case series.

SETTING

Level-1 Trauma Center, London, United Kingdom.

PATIENTS

Consecutive cases of skeletally mature individuals with unstable Lisfranc injuries treated operatively between 2014 and 2019.

INTERVENTION

Open reduction and DBP fixation with implants not routinely removed.

MAIN OUTCOME MEASUREMENTS

Patient-reported outcome measures at final follow-up. The Manchester-Oxford Foot Questionnaire summary index was the primary outcome measure. The American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause reoperation rates were secondary outcome measures. Logistic regression models were used to identify risk factors that influenced outcomes.

RESULTS

Eighty-five patients were included. Mean follow-up was 40.8 months (24-72). The mean Manchester-Oxford Foot Questionnaire Summary Index was 27.0 (SD 7.1) and mean AOFAS score 72.6 (SD 11.6). The presence of an intra-articular fracture was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both P < 0.001). Eighteen patients (21%) required implants removal, with this more likely in female patients (OR 3.89, 95% confidence interval, 1.27 to 12.0, P = 0.02). Eight patients (9%) required secondary arthrodesis.

CONCLUSIONS

This is the largest series of Lisfranc injuries treated with DBP fixation reported to-date and the only to routinely retain implants. Medium-term outcomes are comparable to existing literature in which implants are routinely removed. The presence of an intra-articular fracture is a poor prognostic indicator. Implant removal is more likely to be needed in female patients.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for authors for a complete description of levels of evidence.

Surgical controversies and current concepts in Lisfranc injuries

INTRODUCTION

Lisfranc injuries, not as rare as previously reported, range from ligamentous to complex fracture-dislocations. Anatomical studies have identified a complex of discrete structures, and defined the anatomical characteristics of the Lisfranc joint.

SOURCES OF DATA

A narrative evidence-based review encompassed and analyzed published systematic reviews. Outcomes included clinical and surgical decision-making, including clinical-presentation, diagnosis, pathological-assessment, surgical-management techniques and indications, post-surgical care and comparative outcomes.

AREAS OF AGREEMENT

Better understanding of the Lisfranc complex anatomy aids surgical treatment and tactics. Prognosis is related to injury severity, estimated by the number of foot columns affected. Surgical outcome is determined by anatomical reduction for most fixation and fusion techniques. Appropriate treatment allows return to sport, improving outcome scores.

AREAS OF CONTROVERSY

Identification of Lisfranc injuries may be improved by imaging modalities such as weight-bearing computer tomography. Recent evidence supports dorsal plate fixation as a result of better quality of reduction. In complex injuries, the use of combined techniques such as trans-articular screw and plate fixation has been associated with poorer outcomes, and fusion may instead offer greater benefits.

GROWING POINTS

Open reduction is mandatory if closed reduction fails, highlighting the importance of understanding surgical anatomy. If anatomical reduction is achieved, acute arthrodesis is a safe alternative to open reduction internal fixation in selected patients, as demonstrated by comparable outcomes in subgroup analysis.

AREAS FOR DEVELOPING RESEARCH

The current controversies in surgical treatment remain around techniques and outcomes, as randomized controlled trials are infrequent.

Patient experiences and preferences during treatment and recovery of Lisfranc fractures: A qualitative interview study

AIM

To determine from a patient perspective what improves the quality of care and patient satisfaction during the treatment and recovery process of Lisfranc fractures and to reveal possible points for improvement in this process.

METHODS

We performed a qualitative study based on semi-structured interviews with patients treated for a Lisfranc fracture-dislocation in the Netherlands with either open reduction and internal fixation or primary arthrodesis, until data saturation was reached, focusing on the quality of care during treatment and recovery, from a patient perspective.

RESULTS

Data saturation was reached after interviewing 10 patients. The main themes emerging from the analysis were expectation management regarding the recovery period; communication with and between health care providers; information provided during consultations; and support during the recovery period. Participants expressed a need for improved provision of information about the different treatment options, the different kinds of pain that can arise, the expected duration of the recovery period, education on strong pain killers, likelihood of a second surgery, risks of osteoarthritis, risks of the surgery itself, allied health care and patient experiences. Participants mentioned the importance of good allied health care and a preference for starting allied health care as soon as possible. Insoles and compression socks were also appreciated by various participants. Finally, multiple patients saw a positive attitude on the part of the health care providers towards the recovery period as a key factor in recovery.

CONCLUSION

This study found that patients value more tailored approaches to the pre-and post-operative care program, more guidance regarding allied health care (physiotherapy), and a broader scope of available references and information for patients, both oral (during consultations and in informative videos) and written, such as brochures or evidence-based web pages and mobile platforms, which may be offered during consultations or when being discharged from the hospital.

The First Tarsometatarsal Joint in Lisfranc Injuries

BACKGROUND

Lisfranc injuries are among the most debilitating injuries to the foot. Characterization of first tarsometatarsal (TMT) joint involvement in Lisfranc injuries is limited. Multiple studies have indicated that this joint is damaged in a variety of Lisfranc injury patterns, but there is sparse information regarding how often and in what form.

METHODS

A retrospective review was performed of operative Lisfranc fractures from 2010 to 2020 with patients identified by Combined Procedural Terminology codes. Hardcastle and Myerson Lisfranc injury classifications and computed tomography and radiograph characterizations of the first TMT joint were evaluated by 3 foot and ankle fellowship-trained orthopaedic surgeons. Radiographic characteristics were collected. Light's kappa coefficient evaluated interrater reliability for injury classification. Injury mechanism and Lisfranc classification effects on the first TMT joint were further assessed using inferential statistics.

RESULTS

Of 71 patients with a Lisfranc injury of which 37 (52%) were high energy, 61 (86%) showed radiographic evidence of first TMT joint injury. A fragment was present in the TMT articular surface in 33 (47%) with median size = 8.7 mm and medial capsular avulsion in n = 25 (35%). Forty-eight patients (68%) had medial/lateral TMT joint incongruence ≥2 mm (median overhang = 4 mm), 21 (30%) had dorsal/plantar incongruence (median overhang = 6 mm). Angulation of TMT articular surfaces ≥5 degrees on the transverse/anteroposterior plane occurred in n = 32 (45%) and in n = 12 (17%) on the sagittal/lateral plane, which significantly differed between classifications (P = .020).

CONCLUSION

The overwhelming majority of Lisfranc midfoot injuries seen at our tertiary referral center had imaging evidence of damage to the first TMT joint (86%), and the incidence may be higher. The most common patterns of first TMT joint involvement we found were joint incongruity, articular surface fractures, angulation of the articular surfaces, and medial capsular ligament avulsion fractures. A better understanding of injuries to the first TMT joint can help orthopaedic surgeons with diagnosis.

Factors influencing postoperative residual diastasis after the operative treatment of acute Lisfranc fracture dislocation

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.

The role of three dimension computed tomography in Lisfranc injury diagnosis

PURPOSE

To evaluate the intra/inter observer and diagnostic reliability of 3-dimensional (3D) model reconstruction computed tomography (CT) compared to the traditional two-dimensional (2D) CT when evaluating Lisfranc (LF) injuries.

METHODS

A retrospective study was performed on CT studies of patients with clinically suspected LF injuries examined in the emergency department at medium size medical center. Each CT study was evaluated for metatarsal fractures and subluxations employing both standard 2D and 3D CT model reconstruction. Four orthopaedists, 2 senior and 2 residents, were assigned to review and evaluate each CT. Each CT study was reviewed twice by each reader in a randomized order. Descriptive statistics were calculated for all measured variables. The intra-observer and inter-observer agreement Kappa coefficients were calculated to evaluate reliability and reproducibility between and within readers for each modality.

RESULTS

The study included 44 patients. Median age was 41.4 years (interquartile range, 23-58). The intra-observer and inter-observer reliability was good (intra-observer; 3D Kappa; 0.76 and 2D Kappa 0.73 p<0.001, inter-observer; 3D Kappa 0.68, 2D Kappa 0.63 and combined 2D and 3D kappa 0.68, p<0.001). Three dimensional CT was found to be more sensitive than 2D CT, specifically when evaluating for second metatarsal dislocation (sensitivity: 70% vs 47%). Combined evaluation of 2D and 3D CT, greatly improved sensitivity rate to 85.7%. In terms of fracture diagnosis, combined evaluation of 2D and 3D CT showed higher sensitivity and specificity rates as compared to 2D or 3D alone.

CONCLUSION

The employment of 3D CT in LF injury diagnosis, in isolation and in combination with 2D CT, seems to improve the diagnostic accuracy and reliability between and within observers compared to 2D CT alone.

Pediatric Lisfranc Fracture-Dislocation: A Case Report

Lisfranc injury is extremely rare in the pediatric population and little evidence exists to guide the treatment at this age.

We present a clinical case of a rare Lisfranc fracture-dislocation at pediatric age. An 11-year-old male was admitted to the emergency department, in October 2020, after a motorcycle incident. He was diagnosed with a Lisfranc fracture-dislocation of the right foot: Myerson type B2. Fourteen days after the injury, he underwent surgical treatment with open reduction and internal fixation with 3.5 mm solid fully threaded screws.

At 18 months postoperative, the patient was asymptomatic, didn’t present any limitations, presented an American Orthopedic Foot and Ankle Score (AOFAS) midfoot score of 93%, and excellent results of the 12-Item Short Form Survey (SF-12) - PCS-12 (Physical Score): 52.52277 and MCS-12 (Mental Score): 62.12820. The foot maintained a good configuration without significant malalignment, however, a screw breakage occurred before the implant removal, and a premature physeal arrest developed on the base of the first metatarsal bone.

Clinical and radiographic evaluation of Lisfranc injuries may be challenging in the pediatric population. Regarding the treatment, anatomical alignment is mandatory, and good or excellent outcomes have been achieved with anatomical reduction and internal fixation. We recommend early implant removal to avoid screw breakage and avoid the use of screws in the first metatarsal physis, due to the risk of premature physeal arrest.

An open-source OpenSim® ankle-foot musculoskeletal model for assessment of strains and forces in dense connective tissues

BACKGROUND

The ankle and foot are among the most critical load-bearing joints in the human anatomy. Anatomically accurate human body models are imperative to understanding the mechanics of injury and musculoskeletal disorders. A typical human ankle-foot anatomy consists of 25 DOFs, 112 dense connective tissues (DCTs) (92 ligaments, one capsule and 19 fasciae), 30 tendons, and 65 muscles. Existing models possess less than half of the DOFs and physiological elements. In this work, we have developed an ankle-foot joint complex musculoskeletal model for the OpenSim® platform by incorporating 24 degrees of freedom (DOF) comprising of 66 DCTs (46 ligaments, one 1 capsule and 19 fasciae), 30 tendons, and 65 muscles.

METHODS

Computed tomography (CT) data of human ankle joint-foot complex was segmented using Mimics ® (Version 17.0, Materialise, Belgium) to obtain models of the cartilages and bones of the ankle joint-foot complex. The position and resting lengths of the DCTs were attained from the MRI data and literature. Five joints, namely, tibiotalar, subtalar, chopart, tarsometatarsal (TMT), and metatarsophalangeal (MTP) joints and their joint axes were formulated to yield 24 DOFs. A forward simulation was carried out at each joint of the ankle-foot complex within their respective range of motions. The strains, instantaneous strain rates, and forces developed in the ligaments during the simulation were studied.

RESULTS

During plantar-dorsiflexion of the tibiotalar joint, the anterior tibio-talar ligament (aTTL) yielded the maximum strain compared to all other ligaments. Anterior tibio-fibular ligament (aTFL) experienced extreme strain during subtalar inversion. Hence, the coupled kinematics of subtalar inversion and plantar flexion are failure-prone activities for aTFL. The chopart, TMT, and MTP joints yielded maximum strains or forces for several bundles at the extremes of the range of motion. This signifies that rotations of these joints to their extreme range of motion are prone to failure for the bundles attached to the joint complex.

CONCLUSION

The results illustrate the potential application of the proposed OpenSim® ankle-foot model in understanding the ligament injury mechanism during sports activity and its prevention. Researchers can use the proposed model or customise it to study complex kinematics, understanding injury mechanisms, testing fixtures, orthosis or prosthesis, and many more in the domain of musculoskeletal research.

Clinical and Radiologic Results of a Human Bone Graft Screw in Tarsometatarsal II/+III Arthrodesis

BACKGROUND

For arthrodesis of the tarsometatarsal joints, there is the possibility of using a transplant screw made of allogenic human bone material (Shark Screw). This article investigates the clinical outcome and radiologic integration of the allogenic bone screw for arthrodesis of the tarsometatarsal joints II/+III.

METHODS

This is a prospective study involving 20 feet of 17 patients who received TMT II/+III arthrodesis with an allogenic bone screw. A visual analog scale (VAS pain and function), Foot Function Index (FFI), American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score, and Foot and Ankle Outcome Score (FAOS) were used as measures to compare preoperative with postoperative results. Radiologic integration in the recipient bone was also evaluated.

RESULTS

A significant mean pre- to postoperative improvement of all evaluated scores has been observed (P < .05) after a mean follow-up of 15.87 months (minimum 12 months, maximum 33 months). VAS score (pain) decreased from 7.6 to 1.4 points as well as a decrease of the VAS (function) from 7.25 to 1.8 points. Further, a reduction of the FFI from 62.3% to 16.7% and an increase from 29.7 to 79.9 points of the AOFAS was detected. Analyzing the FAOS score, in all surveyed subscales, there was an increase in the score (Symptoms: 55.2 to 85.6 points; Pain: 30.5 to 86.9 points; Function: 33.1 to 88.3 points; Quality of life: 27.8 to 79.7 points). Moreover, in all cases, a complete radiologic integration into the receiving bone was appreciated, and after a minimum follow-up time from 12 months, the screw in 19 feet (95%) was no longer distinguishable from the original bone.

CONCLUSION

With these first results of the allogenic bone screw in TMT II/+III arthrodesis, a significant improvement from preoperative to postoperative was confirmed in the collected scores, and a full radiographic integration was demonstrated in all feet.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Radiographic outcomes of cortical screw fixation as an alternative to Kirschner wire fixation for temporary lateral column stabilization in displaced Lisfranc joint fracture-dislocations: a retrospective cohort analysis

Background

Injuries of the tarsometatarsal joint complex ranging from purely ligamentous to multidirectionally unstable midfoot fracture-dislocations are anatomically fixed to minimize long-term sequelae including post-traumatic arthritis, pes planus deformity, and chronic pain. Lateral column disruption is commonly treated with temporary Kirschner wire (K-wire) fixation, maintaining alignment during healing and allowing resumption of physiologic motion after hardware removal. More unstable fracture patterns may require temporary cortical screw fixation to maintain adequate reduction. We evaluated the efficacy of temporary lateral column screw fixation compared to K-wire fixation for Lisfranc fracture-dislocation treatment.

Methods

This retrospective cohort study reviewed 45 patients over fourteen years who underwent Lisfranc fracture-dislocation fixation at a level-one trauma center. All patients underwent medial and middle column fixation; 31 underwent lateral column fixation. Twenty six patients remained after excluding those without electronic records or follow-up. The primary outcome was radiographic lateral column healing before and after hardware removal; secondary outcomes included pain, ambulation, and return to normal shoe wear.

Results

Twenty patients were male, with mean age 41 years. Thirteen patients underwent cortical screw fixation and twelve K-wire fixation. One had both implants. Twenty four patients underwent lateral column hardware removal; all had radiographic evidence of bony healing before hardware removal. Mean follow-up was 88.2 ± 114 weeks for all patients. The cortical screw cohort had significantly longer mean time to hardware removal (p = 0.002). The K-wire cohort had significantly more disuse osteopenia (p = 0.045) and postoperative pain (p = 0.019).

Conclusions

Radiographic and clinical outcomes of unstable Lisfranc fracture-dislocation treatment support temporary lateral column screw fixation as an alternate technique.

Level of clinical evidence

3 (retrospective cohort study)