Subtle injuries to the lisfranc joint

The tarsometatarsal joint complex is an osseous and capsuloligamentous network that includes the 5 metatarsals, their articulations with the cuneiforms and cuboid, and the Lisfranc ligament, a strong interosseous attachment between the medial cuneiform and second metatarsal. A multitude of injury patterns exist involving the tarsometatarsal joint complex; a Lisfranc injury does not delineate a specific injury, but instead a spectrum of processes involving the tarsometatarsal joint complex.     

Lisfranc joint injuries: diagnosis and treatment

Injuries to the tarsometatarsal or Lisfranc joint, though rare, are often undiagnosed or inadequately treated, resulting in poor long-term outcomes. Clinical and radiographic data are needed to recognize and treat these injuries for optimal outcomes. In this article, we review the anatomy, biomechanics, injury mechanisms, clinical presentation, radiographic evaluation, injury classification, treatment, outcome, and complications of Lisfranc joint injuries.     

Persistent instability in pure ligamentous Lisfranc joint injuries

IntroductionLisfranc injuries refer to a specific group of injuries which lead to instability of the tarsalmetatarsal joint. Our hypothesis is that persistent instability is permanent and asymptomatic in subtle unstable injuries of the medial column which have been fixed percutaneously.ObjectiveTo describe the persistent instability of pure ligamentous Lisfranc joint injuries treated with anatomic reduction and percutaneous screws fixation by comparative radiographs of both feet.Materials and methodsBetween 2014 and 2018, 14 patients diagnosed with subtle unstable Lisfranc injury were evaluated. Indications for surgery included widening (diastasis) greater than 2 mm between the first and second metatarsal bases, and subluxation greater than 1 mm of a metatarsal base from its respective tarsal bone.ResultsPersistent instability was found on the stress radiographs of 11 patients (78.57% 95% CI: 48.60–95.07%) but without clinical connotations. The average AOFAS score evaluated at 18 months post-operatively was of 97.14 (SD ± 4.68) points. The median follow-up was 24 (RIQ: 18–24) months. In all patients, anatomical reduction on radiographs was evident.ConclusionWe observed a persistent instability of the Lisfranc joint, without clinical connotations.Subtle unstable Lisfranc injuries treated with percutaneous screw fixation have a good clinical and functional outcome.Level of evidence: IV.     

Acute ligamentous injuries of the Chopart and Lisfranc joint line

The foot is a complex structure with numerous articular surfaces. As there are many potential complications (severe edema, compartment syndrome of the intrinsic foot musculature, bone and soft tissue necrosis, joint abnormalities, limitation of movement, deformities, etc.), traumatic surgeons must have a detailed knowledge of the relevant functional anatomy and treatment procedures. If there are multiple injuries, in the context of management, early definitive treatment for the injury is to be stressed. One requirement is an exact clinical and radiological diagnosis. As a rule, closed reduction is therapeutically successful. In a stable injury, immobilization can be achieved with a cast; in open wounds and malalignment of joint surfaces, an operative procedure is indicated. Particular attention must be paid to injuries of the tarsal bones in children to avoid delayed failure of growth, as the results of radiological investigations are often difficult to interpret. The diagnosis, techniques of management, and principles of follow-up are presented.     

Stabilization of Lisfranc joint injuries: a biomechanical study

BACKGROUND: Lisfranc joint injuries are often misdiagnosed, leading to significant morbidity. Methods for anatomic reduction of the tarsometatarsal joint include closed reduction with casting or surgical stabilization with either Kirschner wires and/or cortical screw fixation. Controversy exists as to which fixation technique offers optimal stability. In the present study, the biomechanical stability of three fixation methods was tested: (1) four Kirschner wires, (2) three cortical screws plus two Kirschner wires, and (3) five cortical screws. METHODS: Ten matched pairs of fresh-frozen cadaveric feet were dissected to their ligamentous and capsular elements. The tarsometatarsal ligaments were completely transected to replicate a Lisfranc dislocation; the "injury" was reduced and stabilized using one of the three methods. Biomechanical studies were performed by applying a 100-N cyclic load physiologically distributed to the plantar aspect of the metatarsal heads. Displacement and force measurements were taken from the first and fifth metatarsal heads. Average stiffness of each construct was calculated from the force displacement curves. RESULTS AND CONCLUSIONS: Method 2 provided significantly more stability than Kirschner wire fixation. Method 3 created more stiffness than method 2 at the medial portion of the foot; no statistical difference between the two methods was evident at the lateral foot. CLINICAL RELEVANCE: Cortical screw fixation provides a more rigid and stable method of fixation for Lisfranc injuries as compared to Kirschner wire fixation. This fixation method allows maintenance of anatomic reduction and possibly earlier mobilization with a decreased risk of posttraumatic arthrosis.     

The diagnosis and treatment of injuries to the Lisfranc joint complex

These injuries are associated with considerable morbidity, and successful results depend on understanding the anatomy, understanding pathogenesis, and precise and careful treatment of this injury. Surgical treatment is discussed as well as arguments against the use of conservative treatment.     

Lisfranc injuries

Lisfranc/midfoot injuries are complex injuries that are frequently overlooked. The consequences of missing these injuries can lead to long-term deformity and disability. Timely diagnosis, whether by primary or later treating physicians, can ensure this does not happen. Proper physical examination and imaging studies allow the physician to find these injuries and determine if open treatment is required. Open treatment can be approached and performed in a number of ways, depending on geographical preference. However, one concept that remains across all the various techniques is perfect anatomical reduction before the fixation technique is applied. Intraoperative and postoperative variations are all secondary concerns after anatomical reduction.     

手术治疗Lisfranc关节损伤13例的疗效分析

目的:探讨手术治疗Lisfranc关节损伤的临床疗效及影响因素.方法:自2009年1月至2011年11月,共收治Lisfranc关节损伤13例14足,男9例,女4例;年龄18～61岁,平均42岁.Myerson分型:A型1足,B型9足,C型4足.所有患者在伤后22 d内接受手术,手术采用切开复位螺钉或克氏针内固定(1例开放性采用外固定架固定).术后采用美国足踝外科协会(American Orthopaedic Foot and Ankle Society,AOFAS)足评分标准进行功能评估;术前、术后摄X线正斜或侧位片,进行影像学评估.结果:所有患者获得随访,时间5～30个月,平均20个月.术后根据AOFAS足评分,优8足,良4足,中2足.X线片示12例获得解剖复位,所有患者骨性愈合1例出现皮肤切缘坏死,经换药后愈合;1例开放性骨折皮肤回植后出现坏死,行皮瓣修复后愈合.其余病例未见任何手术并发症.结论:切开复位内固定是治疗Lisfrancs关节损伤的有效方法,术前软组织损伤的评估、术中骨折复位及术后复位的维持可影响临床结果.     

A single surgeon's experience of treatment of Lisfranc joint injuries

This paper assesses the outcomes and complications of Lisfranc joint injuries treated at a regional trauma centre under the care of a single surgeon. We performed a retrospective study of all patients that underwent ORIF of a Lisfranc joint injury over a 5-year period. Case note review, radiology review, and questionnaire assessment were performed. We analysed for correlations between outcome and injury type, mechanism of injury, and presence of other ipsilateral limb injury and pure ligamentous injury. All injuries were classified according to a system described by Myerson et al. (Types A, B1, B2, C1, C2). Radiographs were also assessed for the presence of pure ligamentous injury. Outcome was measured using the American Orthopaedic Foot and Ankle society (AOFAS) midfoot score. Twenty-five injuries (24 patients) were identified and 16 injuries (15 patients) were available for follow. The mean duration of follow up was 42.6 months (11-69). The mean outcome score was 78.3 (38-100). The outcome scores for pure ligamentous injury (74.9) and for mixed bony and ligamentous injury (80.9) had no significant difference (p=0.61). High-energy trauma accounted for 50% of cases, and scored significantly less than low energy trauma (69.1 versus 87.4, p<0.05). There was an associated injury in the ipsilateral limb in 31% of cases and this group had a poorer outcome (63.0 versus 85.3, p<0.035). The most common injury type was B2 (38%). Type C2 injuries (divergent with total displacement) had a worse outcome than the mean outcome of all other categories (60.5 versus 84.4, p<0.01). Our mean outcome from ORIF of Lisfranc joint injuries is comparable to internationally quoted figures. Pure ligamentous injuries did no worse statistically than mixed bony and ligamentous injuries. Poorer outcome was associated with high-energy trauma, associated injury on the ipsilateral limb, and Type C2 injuries.     

Outcome after open reduction and internal fixation of Lisfranc joint injuries

BACKGROUND: Open reduction and internal fixation has been recommended as the treatment for most unstable injuries of the Lisfranc (tarsometatarsal) joint. It has been thought that purely ligamentous injuries have a poor outcome despite such surgical management. METHODS: We performed a retrospective study of patients who underwent open reduction and screw fixation of a Lisfranc injury in a seven-year period. Among ninety-two adults treated for that injury, forty-eight patients with forty-eight injuries were followed for an average of fifty-two months (range, thirteen to 114 months). Fifteen injuries were purely ligamentous, and thirty-three were combined ligamentous and osseous. Patient outcome was assessed with use of the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and the long-form Musculoskeletal Function Assessment (MFA) score. RESULTS: The average AOFAS midfoot score was 77 points (on a scale of 0 to 100 points, with 100 points indicating an excellent outcome), with patients losing points for mild pain, decreased recreational function, and orthotic requirements. The average MFA score was 19 points (on a scale of 0 to 100 points, with 0 points indicating an excellent outcome), with patients losing points because of problems with "leisure activities" and difficulties with "life changes and feelings due to the injury." Twelve patients (25 percent) had posttraumatic osteoarthritis of the tarsometatarsal joints, and six of them required arthrodesis. The major determinant of a good result was anatomical reduction (p = 0.05). The subgroup of patients with purely ligamentous injury showed a trend toward poorer outcomes despite anatomical reduction and screw fixation. CONCLUSIONS: Our results support the concept that stable anatomical reduction of fracture-dislocations of the Lisfranc joint leads to the best long-term outcomes as patients so treated have less arthritis as well as better AOFAS midfoot scores.     

切开复位内固定治疗Lisfranc关节损伤

目的探讨切开复位内固定治疗Lisfranc关节损伤的临床疗效。方法应用切开复位技术,根据骨折类型不同,分别选用螺钉、克氏针及微型钢板作内固定材料,对27例Lisfranc关节损伤患者进行治疗。结果术后患者均未发生感染及骨筋膜室综合征。27例均获随访,时间9～12个月。根据美国足踝外科协会AO-FAS评分标准评估疗效:优13例,良11例,可3例,优良率为88.9%。结论切开复位内固定治疗Lisfranc关节损伤,可以获得良好的临床效果。     

Arthrodesis of the Lisfranc joint

Surgical Principles Arthrodesis of the damaged tarsometatarsal joint following reduction and/or correction of malposition.     

Percutaneous fixation of Lisfranc joint injuries: A systematic review of the literature

ObjectiveThe aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation.MethodsWe searched in Pubmed and Google Scholar Databases for articles regarding screw percutaneous fixation of Lisfranc injuries. Seven studies in total were found to be compatible to our search, according to PRISMA guidelines. Four of those met the criteria of the review and they were included in the meta-analysis. A total number of 106 patients were separated into five groups according to the type of injury and the mean AOFAS score of each group was calculated. Cases in which percutaneous fixation was converted to open treatment due to poor reduction were not included in the study. In addition we compared the outcome score between types of injury according to Myerson classification as well as between purely ligamentous and osseoligamentous injuries. The characteristics of all seven selected studies, such as kind of screw used for fixation, post operative protocol, complications and outcome are mentioned as well.ResultsAverage AOFAS score was 86,2 for type A, 87,54 for type B, and 85 for type C injuries respectively. In pure dislocation group the average AOFAS score was 86,43 and in fracture dislocation group was 87,36. Good to excellent outcome can be expected in patients with different types of injury according to Myerson classification following percutaneous fixation of lisfranc joint injury. Patients with type B injury or a fracture dislocation injury might have better outcome, although this difference was not found to be statistically significant.ConclusionPercutaneous fixation of tarsometatarsal joint injuries is a relatively simple and safe method of treatment, leading to a good functional outcome, especially for Myerson type B as well as for fracture dislocation type of injuries, provided that an anatomical reduction has been achieved.Level of EvidenceLevel III, Therapeutic Study.     

The Lisfranc joint

The Lisfranc joint encompasses 6 articulations, weak dorsal ligaments, and strong plantar ligaments. The Lisfranc ligament serves to secure the second metatarsal in the keystone of the midfoot. Traumatic ligament injury and fracture can result in deformity, instability, pain, and degenerative joint disease of the Lisfranc joint. Increased awareness of Lisfranc joint anatomy and advanced imaging has allowed more accurate diagnosis and treatment of this injured joint complex. Nontraumatic degenerative joint disease can also result from congenital and acquired deformity such as first ray insufficiency, abnormal metatarsal parabola, and equinus. Open reduction with internal fixation (ORIF) demands accurate anatomic alignment to prevent the need for salvage arthrodesis. Early studies have shown that primary arthrodesis of the medial 3 rays has performed equally well or better than ORIF for the displaced primarily ligamentous and severe injuries. A paradigm shift may emerge as more studies favor primary arthrodesis.     

切开复位内固定治疗Lisfranc关节损伤的体会

目的探讨切开复位内固定治疗Lisfranc关节损伤的中短期疗效。方法回顾性分析自2010-01—2013-12诊治的15例Lisfranc关节损伤,分别采用切开复位克氏针、空心钉及背侧钢板内固定,根据美国足踝骨科协会(AOFAS)评分标准对患足术后功能进行评价。结果所有患者均获得随访12~24个月,平均18个月。骨折均达到一期愈合,无皮肤坏死、伤口感染、内固定物断裂、复位丢失等并发症。所有患者均达到解剖复位,根据AOFAS评分标准,平均得分85分,优5例,良9例,可1例。结论切开复位内固定治疗Lisfranc关节损伤可获得良好的中短期疗效满意,能有效恢复患足功能,减少致残率。     

Percutaneous fixation of Lisfranc injuries

Lisfranc injuries may occur in the form of fracture-dislocations or pure ligamentous dislocations or subluxations. These innocuous appearing injuries have the potential for significant morbidity and long-term sequelae resulting in permanent deformities. Ligamentous subluxations account for 20% of these injuries and cases with partial incongruity are amenable to percutaneous fixation. In this article, we present step-by-step percutaneous fixation of these injuries as well as the post-operative management.