Lisfranc injury: A review and simplified treatment algorithm

BackgroundLisfranc injuries encompass large spectrum of injuries varying from low energy to high energy complex fracture dislocations. Whilst multiple complex classification systems exist; these do little to aid and direct the clinical management of patients. Therefore, this study aims to provide a simplified treatment algorithm allowing clinicians to standardise care of Lisfranc injuries.MethodsA comprehensive literature search was performed, and abstracts were reviewed to identify relevant literature.ResultsDelay in diagnosis has a negative impact on outcome. If a Lisfranc injury is suspected and plain radiographs are inconclusive; computed tomography and if necessary magnetic resonance imaging are indicated if there is still an index of suspicion. In the absence of joint dislocation/subluxation management will be determined by stability which can be best assessed by weightbearing radiographs. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks followed by a period of graduated weight bearing. Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return to theatre. With regard to bony unstable Lisfranc injuries more research is required before a single treatment modality - PA or open reduction internal fixation can be advocated, due to the lack of randomized control trials and limited patient follow-up periods in existing studies.ConclusionA simplified treatment algorithm excluding the requirement for complex classifications is suggested. This may help with the diagnosis and management of these injuries. It is our believe that this algorithm will aid health professionals to standardize care for these injuries. Further prospective research trials are required to assess outcomes of different modalities of operative management, particularly with regards to open reduction and internal fixation versus primary arthrodesis for bony Lisfranc injuries.Level of evidenceLevel 5.     

Iatrogenic fracture gapping during fixation of Jones fractures: Anatomic and mechanical considerations in a cadaveric model

BackgroundSurgical fixation of Jones fractures is often recommended to facilitate recovery and achieve union. Iatrogenic fracture displacement during intramedullary screw fixation is a commonly encountered technical issue. This may be related to fracture location in relation to the surrounding ligamentous attachments, namely the robust intermetatarsal ligaments found at the proximal articulation of the 4th and 5th metatarsals. This study examines the relationship between fracture line and its location in regards to the surrounding ligamentous structures and its effect on Jones fracture displacement, reduction and fixation in a cadaveric model.MethodsEighteen fresh-frozen cadaveric feet were dissected with preservation of all ligamentous attachments. Given the similar anatomic distal extent of the dorsal and plantar intermetatarsal ligaments on the 5th metatarsal, measurements were obtained detailing the anatomic position of the dorsal intermetatarsal ligament (DIL) only. The specimens were divided into two groups with modelled fractures created at the 4th & 5th metatarsal articulation proximal to the distal extent of the DIL (Group 1) or just distal to the DIL (Group 2). Fractures were fixed in standard fashion with serial fluoroscopic images obtained to study fracture gapping and rotation.ResultsThere was approximately 5 mm of fracture gapping created iatrogenically during tapping with no statistically significant differences between Group 1 and Group 2 (4.53 mm versus 5.25 mm, p = 0.5430). The distal aspect of the DIL was anatomically located 2.77 mm (Range 1.58 mm–4.46 mm) distal to the 4th & 5th metatarsal articulation.ConclusionsConsiderable iatrogenic fracture gapping occurs during intramedullary screw fixation of Jones fractures in a cadaveric model regardless of fracture location in relation to the intermetatarsal ligamentous attachments. Specific techniques may be required to maintain anatomic alignment during tapping and screw fixation to prevent iatrogenic displacement.Level of evidenceV, Expert Opinion.     

Evaluation of dorsal Lisfranc ligament deformation with load using ultrasound imaging

BackgroundResearch findings have linked dorsal Lisfranc ligament (dLL) rupture to complete Lisfranc ligament complex rupture; identifying deformation characteristics of the dorsal Lisfranc ligament alone may be helpful in diagnosing complete ligament rupture. The goal of the present study was to assess the deformation characteristics of the asymptomatic dLL using physiologically relevant stress/loads in a clinical setting and to discern normative dLL parameters.MethodsUnilateral dLL measurements were taken from 50 healthy volunteers, using sonographic imaging under three different stress/load conditions. Stress/load was applied using the individuals’ bodyweight (low—seated; medium—bilaterally equal weight bearing in standing; and high—single leg standing). Digital images of the dLL captured using ultrasound were visualized to determine the dLL length. One-way repeated measures ANOVA was used to assess changes in the dLL length with load.ResultsThe average dLL elongation, as percent resting length change, was 8.76% between seated and single leg standing positions. Most of the dLL elongation (6.26%) occurred between seated and bilateral standing.ConclusionsThe deformation and role of the dorsal Lisfranc ligament can be observed using sonographic imaging resulting from physiological loading in the clinical setting.Clinical RelevanceThese deformation parameters can be used to generate normative data for diagnostic purposes.     

Lisfranc injuries: Incidence,mechanisms of injury and predictors of instability

BackgroundIn Lisfranc injuries the stability of the tarsometatarsal joints guides the treatment of the injury. Determining the stability, especially in the subtle Lisfranc injuries, can be challenging. The purpose of this study was to identify incidence, mechanisms of injury and predictors for instability in Lisfranc injuries.MethodsEighty-four Lisfranc injuries presenting at Oslo University Hospital between September 2014 and August 2015 were included. The diagnosis was based on radiologically verified injuries to the tarsometatarsal joints. Associations between radiographic findings and stability were examined.ResultsThe incidence of Lisfranc injuries was 14/100,000 person-years, and only 31% were high-energy injuries. The incidence of unstable injuries was 6/100,000 person–years, and these were more common in women than men (P = 0.016). Intraarticular fractures in the two lateral tarsometatarsal joints increased the risk of instability (P = 0.007). The height of the second tarsometatarsal joint was less in the unstable injuries than in the stable injuries (P = 0.036).ConclusionThe incidence of Lisfranc injuries in the present study is higher than previously published. The most common mechanism of injury is low-energy trauma. Intraarticular fractures in the two lateral tarsometatarsal joints, female gender and shorter second tarsometatarsal joint height increase the risk of an unstable injury.Level of EvidenceLevel III, cross-sectional study.     

Lisfranc injuries in adolescents: A case report and literature review

Lisfranc injuries result if bones or ligaments that support the midfoot are torn. In children and adolescents these injuries are not only rare, but are also similar to adult Lisfranc injuries, in that they are often mistaken especially if the injury is a result of a straightforward twist and fall. The goal of surgical treatment is to realign the joints.However, few studies related to Lisfranc injuries in pediatric patients exist.A case of 15 years old patient treated using an Arthrex mini tight rope is described.     

Herbert钉治疗Lisfranc关节骨折脱位

<正>2010年9月~2013年5月,我院收治13例Lisfranc损伤患者,给予切开复位、Herbert钉结合克氏针内定,效果满意,报道如下。1材料与方法1.1病例资料本组13例,男8例,女5例,年龄21~52岁。左侧7例,右侧6例。按Myerson分型:A型2例,B型4例,C型7例。按Myerson三柱分类:中柱损伤3例,中柱合并内侧柱损伤4例,三柱损伤6例。1.2手术方法硬膜外麻醉。足背第1、2跖骨基底作纵行切口,显露第1、2     

Validity and internal consistency of the American Orthopaedic Foot and Ankle Society Midfoot Scale in patients with Lisfranc injury

BackgroundThe American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale is an extensively used outcome measure instrument for evaluating outcomes after foot and ankle surgery or trauma.MethodsIn total, 117 patients with Lisfranc injury completed the AOFAS Midfoot Scale and the Visual Analogue Scale Foot and Ankle (VAS-FA) instruments. Internal consistency (correlation between different items), floor and ceiling values, convergent validity, item threshold distribution, and the coverage (item difficulty) of the AOFAS Midfoot scale were tested.ResultsAOFAS Midfoot Scale had high convergent validity and acceptable internal consistency (Cronbach’s alpha >0.70). The ceiling effect was confirmed. The person-item distribution indicated that the scale had a lack of coverage and targeting in our sample.ConclusionsOur data suggests that the AOFAS Midfoot Scale has acceptable validity and internal consistency. However, due to the lack of coverage and targeting, it should not be the primary outcome measure to be used to evaluate the outcomes after Lisfranc injury in the future studies.     

Open fractures-dislocations of the tarsometatarsal (Lisfranc) joints Report of three cases

Summary Between 1991 and 1992 three patients (21-17-27-year-old males) with open fracture-dislocation of the tarsometatarsal joint were managed in our Department. Two of the patients had type II injuries and the third a type III. There was severe soft tissue damage and therefore, a high risk of infection and necrosis.The diagnosis was easy in every case. They were all managed surgically 1–3 hours after their appearance at hospital and in any case, during the first 8 hours following the injury. They had debridement and reduction. Fixation was achieved with K-wires.Postoperatively a short leg cast was applied and antibiotics were given. The cast was maintained for six weeks. Then the K-wires were removed and progressive weight-bearing was allowed. After a follow-up period of 28-43-4o months, only the second patient has complained of mild pain during his military service. All have developed flatfoot.     

克氏针外固定架联合固定治疗Lisfranc损伤

<正>2002年2月~2011年7月,笔者应用克氏针外固定架联合固定治疗32例Lisfranc损伤患者,疗效确切,报道如下。1材料与方法 1.1病例资料本组32例,男22例,女10例,年龄18~65岁。闭合伤28例,开放伤4例。单纯Lisfranc损伤24例,合并Chopart关节损伤8例;按照Myerson分型[1]:单纯内侧柱损伤14例,内侧柱合并中柱损伤12例,三柱损伤6     

Conservative management of Jones fractures with immediate weight-bearing in a walking boot demonstrates healing

Jones fractures, or proximal metatarsal fractures at the level of the fourth and fifth intermetatarsal junction, have a high risk for nonunion due to a vascular watershed region. Classically, treatment consists of weight bearing restrictions in a cast or surgical fixation. Some studies have assessed immediate weight bearing following a Jones fracture. Due to conflicting results, the most appropriate treatment method remains unclear. This study analyzes outcomes after treating adults with acute Jones fractures non-operatively without weight bearing restrictions in a walking boot. This study hypothesizes that patients will not require future operative intervention following functional treatment.A retrospective review of 55 adult patients who sustained acute, closed Jones fractures was conducted. 47 were treated weight bearing as tolerated (WBAT) in a walking boot and eight were treated non-weight bearing (NWB) in a cast. They were followed radiographically by an orthopedic surgeon for an average of 6.4 and 15.5 months, respectively.Three patients in each group (6.4% WBAT, 37.5% NWB) developed painful nonunion leading to surgical fixation. Thirty (66.7%) patients in the WBAT group demonstrated radiographic union on final radiographs. Only two (13.3%) of the 15 patients with partial union were seen at least six months from time of injury, one of whom had ongoing pain but declined surgery. The remaining 13 patients were asymptomatic at their final clinic appointment.Controversy still exists as to the best treatment methodology for acute Jones fractures. Due to a lack of clear guidelines, it can be difficult for the multiple medical specialties involved to evaluate and treat this injury. Our study suggests that non-operative management of minimally displaced Jones fractures, in the adult, low demand population, without weight bearing restrictions in a walking boot offers similar outcomes to cast immobilization with weight bearing restrictions, resulting in bony union or asymptomatic fibrous nonunion.     

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

BackgroundControversy exists regarding optimal primary management of Lisfranc injuries. Whether open reduction internal fixation (ORIF) or primary arthrodesis is superior remains unknown.MethodsA national insurance database of approximately 23.5 million orthopedic patients was retrospectively queried for subjects who were diagnosed with a Lisfranc injury from 2007 to 2016 based on international classification of diseases (ICD) codes (PearlDiver, Colorado Springs, CO). Patients with lisfranc injuries then progressed to either nonoperative treatment, ORIF, or primary arthrodesis. Associated treatment costs were determined along with complication rate and hardware removal rate.Results2205 subjects with a diagnosis of Lisfranc injury were identified in the database. 1248 patients underwent nonoperative management, 670 underwent ORIF, and 212 underwent primary arthrodesis. The average cost of care associated with primary arthrodesis was greater ($5005.82) than for ORIF ($3961.97,P = 0.045). The overall complication rate was 23.1% (155/670) for ORIF and 30.2% (64/212) for primary arthrodesis (P = 0.04). Rates of hardware removal were 43.6% (292/670) for ORIF and 18.4% (39/212) for arthrodesis (P < 0.001). Furthermore, 2.5% (17/670) patients in the ORIF group progressed to arthrodesis at a mean of 308 days, average cost of care associated with this group of patients was $9505.12.DiscussionPrimary arthrodesis is both significantly more expensive and has a higher complication rate than ORIF. Open reduction and internal fixation demonstrated a low rate of progression to arthrodesis, although there was a high rate of hardware removal, which may represent a planned second procedure in the management of a substantial number of patients treated with ORIF.Level of evidence:Level III Retrospective Cohort Study.     

Lisfranc损伤的诊断和治疗

目的探讨L isfranc损伤的诊治方法及影响疗效的因素。方法对63例L isfranc损伤患者的手术方法、疗效及并发症进行分析。结果46例随访1~8年(平均3年)。感染6例,克氏针松动6例,创伤后关节炎10例。依据美国矫形足踝协会(AOFAS)足评分标准对患足术后的功能进行评定。骨折脱位40例:好25例,较好10例,差5例。单纯韧带损伤6例:较好3例,差3例。结论L isfranc损伤的解剖复位、稳定固定是获得良好预后的关键,而单纯韧带损伤远期疗效不佳。     

Lisfranc fracture dislocation in a child

A case of Lisfranc fracture dislocation complicated by compartment syndrome is reported in a 9-year-old boy who fell from a 5 ft high wall which subsequently collapsed onto him crushing his lower limbs. The patient also sustained an undisplaced, open fracture of the contralateral tibia. The Lisfranc fracture dislocation was treated with open reduction and internal fixation using Kirschner wires (K-wires). Fasciotomy was performed to decompress the foot. The open tibia fracture was treated with wound debridement and plaster cast. The K-wires were removed at 10 weeks follow up. The patient had no complaints on examination and radiographs revealed good evidence of healing. We emphasize the importance of prompt diagnosis and treatment.