Lisfranc Injuries Research Articles

Long-term results of staged management of complex lisfranc and chopart injury: a retrospective cohort study and systematic literature review

PurposeThe aim was to assess the long-term functional outcome and quality of life after staged surgical treatment of complex Lisfranc and Chopart injuries in a patient cohort, and to perform a systematic review of the literature.MethodsA retrospective cohort of all trauma patients with complex Lisfranc and/or Chopart injuries treated at our level 1 trauma center between July 1, 2010, and July 1, 2020 with ≥ 3 years follow-up was analyzed in terms of management, complications, and patient-reported outcomes (American Orthopaedic Foot & Ankle Society midfoot score, AOFAS and Foot Function Index, FFI). A systematic review of the literature (according to PRISMA 2020 guidelines) was performed of studies published between January 2000 to April 2024. Inclusion criteria were acute, complex Lisfranc and/or Chopart injury, staged treatment, age ≥ 17 years, patient-reported outcome measures and ≥ 1 year follow-up.ResultsFifteen patients with a median follow-up of 6.6 years (interquartile range 4) were included. First stage treatment involved temporary K-wire fixation (n = 11), debridement (open fractures, n = 4), external fixation (n = 4) and decompression fasciotomy (n = 3). Second stage included primary arthrodesis (n = 4), open reduction and internal fixation (n = 7) or external fixation (n = 1). The median number of surgeries was 3 (2–13). Infection was seen in 5/15 patients; 7/11 patients underwent secondary arthrodesis and one patient underwent amputation due to chronic pain. Overall AOFAS was fair (54.5) and five patients had poor outcome (AOFAS < 49). Three full-length articles were included in the systematic review, reporting fair to good outcome. Risk of bias was serious and certainty of evidence very low.ConclusionSurgical management of complex Lisfranc and Chopart injuries is challenging, functional outcome was poor to fair, postoperative complication rates are high, and secondary salvage arthrodesis was required in two thirds of ORIF patients.Level of evidenceIV

Lisfranc Injury: Medial Columellar Dislocation M1C1 Associated with a Fracture of the 2nd and 3rd Metatarsal in a Young Soccer Player

Representing only .2% of all fractures, Lisfranc injuries are rare and uncommon. High energy accidents as well as low energy accidents can cause them, and can go from a simple sprain to a full dislocated-fractured injury. Here we are reporting a case of a 17 years old male athlete who presented a medial columellar dislocation M1C1 following a soccer game incident. Management consisted in closed reduction and immobilization in a posterior splint for 6 weeks. Both clinical and radiological results were satisfying in short, medium and long term. Our patient went from passive rehabilitation after 6 weeks, to partial weight bearing after 9 weeks, and then a full weight bearing at 14 weeks gradually returning to his soccer training, individually first and then collectively. At the last follow up, 2 years after the incident, our patient regained full and painless professional activity. This study purpose was to shed light on the potential good results of the non-operative treatment in Lisfranc injuries even in athletic/high performance patients.

Efficacy comparison of dorsal approach and medical approach in treating Lisfranc injury

Objective: To compare the efficacy of dorsal approach and medial approach in the treatment of Lisfranc injury. Methods: A retrospective cohort study was conducted to analyze the clinical data of 43 patients with closed Lisfranc injuries admitted to Tongji Hospital of Tongji University from January 2017 to December 2021. The surgical approach were open reduction and internal fixation or metatarsal cuneiform joint fusion, with 23 cases using the dorsal approach and 20 cases using the medial approach. The duration of surgery, incisional complications, loss of internal fixation, internal fixation removal rate, patient's clinical satisfaction, and American Orthopedic Foot and Ankle Society (AOFAS) score and visual analogue scale (VAS) score of pain in the patients were reviewed based on the medical record system and follow-up records. Results: Of the patients, 33 were male and 10 were female, with a mean age of (45.2±13.4) years. All the patients were followed up for (17.9±6.7) months, and there was no statistically significant differences in the baseline data between the two groups. Preoperatively, the dorsal approach group and the medial approach group had a AOFAS score of (30.3±10.7) and (28.5±9.3), respectively, and a VAS score of (6.2±1.9) and (6.3±2.1), respectively (both P>0.05); the operation time was (112.2±25.0) min and (91.0±22.5) min, respectively in the two groups (P=0.006). Two patients in the dorsal approach group developed superficial infection in the incision, one patient experienced delayed healing in the medial approach group, while the remaining patients achieved primary healing. In the dorsal approach group, three patients suffered long-term numbness or pain on the dorsum of the foot during follow-up, which was alleviated with neurotrophic medications; in the medial approach group, one patient had abnormal sensations around the wound site, which gradually improved. During the follow-up period, a total of 10 patients underwent internal fixation removal, including 7 patients (30.4%) in the dorsal approach group and 3 patients (15.0%) in the medial approach group (P=0.294). The AOFAS score in the dorsal approach group and the medial approach group at the last follow-up was 83.8±7.7 and 86.7±6.9 (P=0.207), and the VAS scores was 2.1±1.0 and 1.3±0.5 (P=0.002), respectively, both showed improvement when compared with those before the surgery (both P<0.001). In both groups, the internal fixations were all in place, with no cases of lost implants. In the dorsal approach group, 3 patients (13.0%) were dissatisfied with the surgical outcome, while in the medial approach group, 1 patient (5%) was dissatisfied (P=0.848). Conclusions: Both surgical approaches resulted in a good prognosis, and there is no statistical difference between the two groups in terms of fixation effect, and the medial approach group is superior to the dorsal access in operative time, internal fixation removal rate, VAS score and patient clinical satisfaction.

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

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. 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). 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. 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. I.

Survey of Utilization of Weightbearing Computed Tomography Within AOFAS Membership.

Weightbearing computed tomography (WBCT) has been increasingly employed to evaluate and treat patients with varied pathologies such as progressive collapsing foot deformity (PCFD), posttraumatic deformity, hallux valgus, ankle arthritis, Charcot arthropathy, lisfranc, and syndesmosis injuries. However, little is known regarding its overall availability to foot and ankle providers and how it is being used in clinical practice. The goal of this study is to assess the utilization of WBCT among AOFAS members, identify the indications for use in clinical practice and potential barriers for implementation. A survey was emailed to AOFAS members inquiring about the use WBCT in clinical practice. Practice and demographic information were also collected. A total of 220 responses were collected over a 2-month period. Respondents were queried with respect to the availability of WBCT in practice, indications for use, frequency of use, ownership of the scanner, and barriers to implementation. 58% of respondents did not have access to WBCT. Most respondents were in practice 10 years or more (69%). Single-specialty private practice was the most common practice type (39%). Of those with access to WBCT, 5 or fewer scans were ordered per week (57% of respondents). Evaluation of hindfoot/ankle deformity was the most common indication (69% of respondents) with it being used as a preoperative evaluation tool approximately 25% of the time (57% of respondents). Radiology department owned WBCT in most institutions (34%). 75% of respondents with WBCT use it postoperatively less than 25% of the time. Of those without WBCT, 94% stated they would like to have it with cost being the most significant barrier to implementation. Most respondents surveyed did not have access to WBCT, with cost being the greatest barrier. However, 94% of those without it would like to have access to it. For those with access, it is used 5 or fewer times per week with evaluation of hindfoot/ankle deformity being the most common indication. Level IV (Observational Study).

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.

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 oneC2 (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, theSF-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.

Epidemiology, classification, and treatment of 2084 Lisfranc injuries: An observational study from the Swedish fracture register

BackgroundLisfranc injuries are potentially severe but relatively uncommon. Limited epidemiological data regarding Lisfranc injuries of the midfoot are available. This study aimed to describe the injury's epidemiology, injury mechanism, and primary treatment. MethodsAn observational register study examined all Lisfranc injuries registered in the Swedish Fracture Register from 2013 to 2022. Data on sex, age, date of injury, injury type, injury mechanism, and primary treatment were analysed. ResultsSome 2084 Lisfranc injuries in 2079 patients (54 % men) were included in the study. The mean age at injury was 43 (18–92, SD 17.3) years for men and 49 (18–96, SD 17.4) for women. One of five cases were caused by high-energy trauma, and the most common injury mechanism was a simple fall - tripping (31 %). Approximately 39 % of patients underwent operative treatment, with fixation using plates (51 %) being the prevailing choice of treatment. Primary arthrodesis was performed in 11 % of the operatively treated cases. ConclusionsLisfranc injuries are the consequence of a broad spectrum of injury mechanisms, are primarily induced by low-energy trauma and found in all age groups in adults. The majority of Lisfranc injuries are treated non-operatively. This comprehension can aid in accurate diagnosis and management in everyday clinical practice.

Functional Outcome and Patient Satisfaction After Primary vs Secondary Arthrodesis for Lisfranc Injuries: Toward a Single-Surgery Approach.

The choice between primary arthrodesis (PA) and open reduction and internal fixation (ORIF) for acute Lisfranc injuries remains contentious. Apart from primary treatment, arthrodesis is often used for treating chronic Lisfranc injuries, including patients in whom initial ORIF or nonoperative treatment failed. The aim of this study was to compare PA and secondary arthrodesis (SA) in terms of complications and functional outcome. A retrospective cohort study was conducted on trauma patients with Lisfranc injuries treated at a level 1 trauma center between July 1, 2010, and July 1, 2020. Selected patients were evaluated at the outpatient clinic and received a survey. Demographics, injury characteristics, management, complications, and patient-reported outcomes (American Orthopaedic Foot & Ankle Society midfoot score, Foot Function Index) were analyzed. Twenty-nine of 37 potential patients (78.4%; PA n = 11, SA n = 18) completed the survey with a median follow-up of 7.1 (PA) to 9.3 (SA) years (P = .01). The majority were female (n = 18, 62.1%); the mean age of PA patients was 57.1 years (SD 14.2) compared with 43.5 years (SD 17.1) in SA patients (P = .04). In the PA group, there was no infection, 100% union, and implants were removed in 5 of 11 patients. In the SA group, 11.1% (n = 2) developed infection, malunion rate was 11.1%, implants were removed in 33.3% (n = 6), and 22.2% required revision surgery. AOFAS was "good" in PA (77.7, SD 17.3) compared with rated "fair" in SA (67.1, SD 21.3, P = .19). FFI was better in PA (26.0, SD 26.2) than SA (37.6, SD 30.8, P = .32), which exceeded the minimally important clinical difference. Although this study was limited by sample size, the overall results suggest equivalent functional outcome, pain and treatment satisfaction in primary arthrodesis compared with secondary arthrodesis patients for treatment of Lisfranc injury.

The missed chapter on midfoot: Chopart injuries

PurposeMidtarsal injuries are often missed at initial presentation which may lead to long-term complications. Nonetheless, radiographs (XR) are used as a primary imaging method. The place of cone beam computer tomography (CBCT) remains unclear in the management of midfoot injuries. The aim of this study was to update imaging findings on traumatic ankle and foot injuries (TAAFI) with CBCT and to assess the sensitivity, specificity and accuracy of XR compared to CBCT for midfoot injuries detections.Material and methodsAll CBCT studies performed due to (TAAFI) that had previous XR were collected for a period of 5 years. They were retrospectively anonymized and analyzed by a radiologist. A second blinded study of XR was made by a second radiologist as a control.ResultsA total of 754 cases were included. Lisfranc and Chopart injuries were detected in 153 (20.2%) and 154 (20.4%) patients, respectively. Lisfranc and Chopart’s lesions combined together were seen in 33 cases (10.7%). A blinded retrospective analysis of XR compared to CBCT shows a sensitivity of 64.9% (56.8–72.4%; 95% CI), a specificity of 95.0% (92.9–96.6%; 95% CI) and an accuracy of 88.9% (86.4–91.0%; 95% CI) for Chopart’s injuries. Regarding Lisfranc, the sensitivity was 62.1% (53.9–69.8%; 95% CI), specificity 99.0% (97.8–99.6%; 95% CI) and accuracy 91.5% (89.3–93.4%; 95% CI).ConclusionThis cohort study highlights the missed injuries of Chopart on XR and the low association with Lisfranc avulsions. The use of CBCT helps in detecting and assessing midfoot injury.

Cross-leg flap, alternative surgery for post traumatic soft tissue defect of ankle and foot

BackgroundSoft tissue defects that afflict the ankle and foot are mostly the result of trauma. Large wounds with soft tissue defects, especially in the ankle and foot, are a reconstructive challenge due to the lack of availability of local tissues and recipient vessels. Case PresentationWe report a female with a crush injury of the right foot and a Lisfranc injury due to a motor vehicle accident. The patient had a soft tissue defect 20 × 10 cm2 with bone and tendon exposed. The patient had a fasciocutaneous flap from the posteromedial of the distal contralateral leg for soft tissue reconstruction. Both legs were stabilized with a cast. The cross-leg flap was separated from the donor site three weeks later, and K-Wire was removed. Flap evaluation was good, and the patient resumed normal gait and activity without any stiffness of joints related to the flap or cast. DiscussionReconstruction of soft tissue defects in the ankle and foot is a challenge for surgeons due to the paucity of local and regional tissues and associated vessel injuries. Cross-leg flap can be suitable alternative option. In this case, we use medially based fasciocutaneous perforator cross-leg flap, based on the posterior tibial artery perforators. Cross-leg flaps are less technically demanding, and the probability of reexploration is lower than in free flaps. The cross-leg flap has the disadvantage of prolonged immobilization and uncomfortable resting positions. ConclusionCross-leg flap can be alternative solution for covering large soft tissue defects in ankle and foot with its advantages and disadvantages.

Convolutional Neural Networks Accurately Diagnose Lisfranc Injuries on Weightbearing and Nonweightbearing Radiographs

Category: Other; Midfoot/Forefoot Introduction/Purpose: Convolutional neural networks (CNNs) predict Lisfranc injuries on weightbearing radiographs. Lisfranc injuries can be misdiagnosed 20%-50% of the time, thus leading to long-term sequela such as midfoot arthritis. Often Lisfranc injuries present to the Emergency department or general practitioner's office where Lisfranc injuries are more frequently misdiagnosed, and weightbearing films are less frequently obtained. CNNs are utilized to classify images, in particular, CNNs are successful at radiographic diagnosis of fractures, Lisfranc injuries, and classification of medical imaging. We aim to utilize CNNs to accurately diagnose Lisfranc injuries on both weightbearing and nonweightbearing films in a generalizable population of patients presenting to the emergency department, general practitioner, and orthopaedic clinics. Hypothesis: CNNs will accurately predict Lisfranc Injuries on weightbearing and nonweightbearing radiographs. Methods: In a retrospective study of 120 patients, 73 with Lisfranc injuries, and 47 without Lisfranc injuries were identified through medical record and imaging review. Radiographs and chart review were utilized to diagnose patients into Lisfranc and Not Lisfranc cohorts. A resnet-50 CNN model was trained, validated, and tested in a ratio (70:20:10) for each imaging view (anteriorposterior, lateral, oblique). Sensitivity, specificity, positive predictive value, negative predictive value, accuracy, F score, and area under the curve (AUC) were calculated for each model and compared between weightbearing and nonweightbearing films. Results: The best deep learning model for Lisfranc identification has 94.5% sensitivity, 78.7% specificity, 90.2% negative predictive value, 87.3% positive predictive value, 88.3% accuracy, 90.8% F score, and 91.5% AUC. Only 2 out of 48 Lisfranc injuries were missed on nonweightbearing films and 3 out of 25 Lisfranc injuries were missed on weightbearing films. Conclusion: CNNs identify Lisfranc injuries on weightbearing and nonweightbearing radiographs with acceptable accuracy. The best model missed fewer Lisfranc injuries than frequently reported numbers for trained radiologists. F score and AUC indicate that this is an excellent test. This provides a method to improve and supplement diagnosis in patients with acute foot injuries, thus limiting long-term sequela from misdiagnosed Lisfranc injuries.

The Presence of An Avulsion Fracture of the 1st Tarso-Metatarsal Joint in Lisfranc Injuries is a Useful Adjunct in Detecting 1st TMTJ Instability

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc fracture-dislocations are uncommon injuries that are often missed or diagnosed late. The consequences of this include post-traumatic osteoarthritis and deformity. Injuries with ligamentous involvement injuries often have avulsion fractures at the level of the tarso-metatarsal joint (TMTJ) on either plain radiographs or CT scan. A proportion of these will have a congruent TMTJ joint on initial imaging. However, it has been suggested that many of these patients will have an unstable TMTJ which requires stabilisation. The purpose of this study was to determine the relationship between the presence of an avulsion fracture on initial imaging and instability or incongruence of the first TMTJ. Methods: A prospectively maintained database of all Lisfranc fracture-dislocations presenting to our centre was collected. Initial plain radiographs and CT scans were analysed for the presence of 1st TMTJ avulsion fractures independently by two senior authors. Data were collected regarding the initial mechanism of injury, fracture classification (Myerson and Qenu). Injuries which were managed non-operatively were excluded from the study. All included cases were managed with examination under anaesthesia (EUA) and intra-operative screening with stress testing under image intensification prior to fixation or arthrodesis surgery. The rate of instability for each fracture classification type was also determined. The sensitivity and specificity of the presence of an avulsion fracture of the 1st TMTJ in detecting an unstable joint was determined. Results: 153 patients with a Lisfranc injury were included. The mean age was 35.2 years, and 68% of patients were male. 99 injuries (64.7%) were identified as having an avulsion fracture at the level of the 1st TMJ on either plain radiographs or CT scan. Of these, 76.7% were found to have a congruent joint on XR or CT scan. 91.9% of patients with an avulsion fracture of the 1st TMTJ were found to have instability on EUA stress testing. Amongst the 54 patients who had no avulsion fracture, 23 (42.6%) demonstrated instability of the 1st TMTJ on EUA. The presence of an avulsion fracture of the 1st TMTJ had a sensitivity of 79.8% and a specificity of 79.5% in the detection of an unstable joint. Conclusion: The presence of an avulsion fracture of the 1st TMJ is highly suggestive of instability of the joint and may be a useful adjunct in assessment and decision making for Lisfranc injuries. This finding on pre-operative radiographs should alert clinicians to have a low threshold to perform further imaging in the form of CT scanning or EUA and dynamic stress testing of the 1st TMTJ. A high proportion of Lisfranc injuries without avulsion fractures have instability at the level of the 1st TMTJ, and therefore the absence of this finding does not provide a reliable indication of joint stability.

Percutaneous Treatment with Bridge Plate in Low-Energy and High-Energy Lisfranc Injuries

Category: Trauma; Other Introduction/Purpose: Although there is still no consensus regarding the optimal treatment approach to both high and subtle Lisfranc injuries, and even when achieving both anatomic reduction and joint complex alignment restoration, percentages of secondary osteoarthritis remain high. Besides the initial chondral damage, the perforation of the different articular facets, necessary for stabilization with position screws, could also influence the articular degeneration evolution. This work aims to show the clinical and radiographic results of a prospective patient cohort followed over three years, obtained by indirect reduction and percutaneous fixation with bridge plate and extraarticular screws in both subtle and high-energy Lisfranc injuries. Methods: A prospective, observational, cross-sectional study of 27 consecutive Lisfranc patients was carried out. Upon diagnosis, patients underwent percutaneous plate and extraarticular screw fixation. Quality of reduction was considered “anatomical” when no diastasis was observed between the first and second metatarsal bases, “almost anatomical” with less than 2 mm of incongruence present, and “non-anatomical” if incongruence was greater than 2 mm. AOFAS midfoot score was utilized for clinical evaluation. Results: 27 patients with a mean age of 31.1 years and a mean follow-up was 35.5 months were analyzed. 17 sustained high-energy lesions while 10 presented low-energy injuries. The postoperative AOFAS score at the final follow-up was 81 points. Patients with an increased number of columns affected, evident unstable Lisfranc injuries, increased age, or staged procedures were associated with lower AOFAS scores. Global quality of reduction positively correlates with the AOFAS score, although no statistically significant association between the number of columns affected and the quality of reduction achieved by this technique was observed. 4 of 27 patients progressed to osteoarthritis and one of them needed further arthrodesis at less than a year after the procedure. No patient presented major wound-related complications. Conclusion: We perform fixation with plates via proximal and distal portals. To serve the purpose of being less possibly aggressive with the joint, screws could be avoided, except for the one necessary to restore the position of the second metatarsal base and the first cuneiform. In this series patients with high-energy injuries depicted good functional results with a high percentage of anatomical reductions over time, with no statistical differences from the low-energy group. The lesser manipulation of the soft tissues needed is probably one of the reasons for the low percentage (7 %) of surgical site infections we report.

Lower Extremity Trauma is Associated with an Increased Rate of New Mental Disorder Diagnosis and Suicide Attempt.

To evaluate the risk of developing a new mental disorder diagnosis within two years of lower extremity fracture. Design: Retrospective cohort study. National insurance claims database. Included were patients between the ages of 18 and 65 with lower extremity, pelvis and acetabular fractures without prior mental disorders as defined with ICD-9 and ICD-10 diagnosis codes. Mental disorders evaluated included alcohol use disorder, generalized anxiety disorder, bipolar disorder, major depressive disorder, drug use disorder, panic disorder, post-traumatic stress disorder, and suicide attempt.Outcome Measures and Comparisons: The individual lower extremity fracture cohorts were matched 1:4 with non-fracture controls. The specific groups of interest were pelvis fractures, acetabulum fractures, proximal femur fractures, femoral shaft fractures, distal femur fractures, patella fractures, tibia plateau fractures, tibia shaft fractures, ankle fractures, pilon fractures, calcaneus fractures, and Lisfranc fractures. Rates of mental disorders after primary lower extremity fractures within two years were compared using multivariable logistic regression. Overall, the 263,988 patient fracture group was 57.2% female with an average age of 46.6 years. Compared to controls with no fracture, patients who sustained pelvis, acetabulum, proximal femur, femoral shaft, distal femur, patella, tibia plateau, tibia shaft, pilon, calcaneus, or Lisfranc fracture had a statistically significant increased risk of being diagnosed with a queried mental disorder within two years of fracture. When comparing all fracture patients by location, those suffering from fractures proximal to the knee joint, including pelvis fractures (OR: 1.51, 95% CI: 1.39-1.64) and proximal femur fractures (OR: 1.36, 95% CI: 1.26-1.47), demonstrated greater risk of developing any of the queried mental disorders compared fractures distal to the knee, including ankle fractures (OR: 0.99, 95% CI: 0.95-1.03) and pilon fractures (OR: 1.05, 95% CI: 0.81-1.36). When comparing specific fracture patients to patients without fracture by mental disorder, patients demonstrated an increased risk of suicide attempt following fracture of the pelvis, acetabulum, femoral shaft, distal femur, and calcaneus, as well as patients suffering a Lisfranc fracture. There is an increased risk of being diagnosed with a new mental disorder following lower extremity trauma in patients without prior mental disorder diagnosis compared to matched individuals without a lower extremity fracture. Among the fractures studied, those that were more proximal, such as pelvis and proximal femur fractures, carried the greatest risk compared to more distal fracture sites, including ankle and pilon fractures. Patients who experienced certain lower extremity fractures had a significantly higher rate of suicide attempt compared to patients without fracture. Physicians should consider increased mental health screening and potential referral for mental health evaluation for patients following lower extremity trauma. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

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. 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. 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. 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.

The Use of Diastasis to Determine Lisfranc Instability

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc injuries have a reported incidence of 1 in 55,000 people. However, given the subtle displacement present in some of these injuries, up to one third are missed on initial diagnosis. Weightbearing imaging is the gold standard for evaluation and diagnosis of the Lisfranc complex, and diastasis between the medial cuneiform and second metatarsal (C1-M2) is the most commonly discussed parameter. However, no explicit consensus on precisely where within the Lisfranc complex to measure the diastasis has been established. Therefore, the aim of this study was to determine what specific diastasis measurement is most sensitive in diagnosing Lisfranc instability using weightbearing radiographs and computed tomography (WBCT). Methods: A total of 159 adult patients with bilateral foot WBCTs were included: 44 with confirmed Lisfranc instability and 115 controls. A subset had unilateral weightbearing X-rays (38 and 83 patients, respectively). Lisfranc instability was confirmed intraoperatively or by physical exam. Exclusion criteria were: prior midfoot surgery, Charcot arthropathy, severe midfoot arthropathy, cuneiform fractures, and significantly displaced 1st-3rd metatarsal base fractures. In the axial plane, C1-M2 diastasis was measured on weightbearing radiograph and WBCT. In the coronal plane, diastasis was measured at different levels between C1-M2 (dorsal, interosseus, plantar, planter apex) and C1-M3 (plantar apex) on WBCT. For WBCT measurements, percent difference between feet was calculated. Case and control measurements were compared with Mann-Whitney U tests (p &lt; 0.05). Diagnostic cutoffs were determined using receiver operator curves (ROC) and minimum distance to the corner. Sensitivity, specificity, negative and positive predictive values, and area under the curve were calculated for each cutoff value. Results: A significant portion of the subjects were female (Lisfranc instability: 60% and controls: 61%). Average age was 39±17 years and 44±17 years for the Lisfranc instability and control groups, respectively. Mann-Whitney U testing revealed a significant difference between groups for all measurements except plantar C1-M2 (p=0.13), C1-M2 plantar apex (p=0.69) and C1-M3 plantar apex (p=0.07). Figure 1 summarizes the diagnostic cutoff values and the associated efficacy measures. Axial WBCT diastasis was the most effective diagnostic measure, followed by dorsal coronal WBCT diastasis. Using a percent difference cutoff of 34%, axial WBCT diastasis (AUC=0.90) demonstrated outstanding diagnostic capability. Dorsal coronal WBCT diastasis with a percent difference cutoff of 46% (AUC=0.80) demonstrated excellent capability. The remaining measurements provided less reliable diagnostic capability, including diastasis on radiograph (AUC=0.77). Conclusion: Axial WBCT diastasis and dorsal coronal WBCT diastasis both effectively diagnose Lisfranc instability on WBCT, with axial WBCT diastasis demonstrating outstanding diagnostic capability. The traditional method of C1-M2 diastasis on weightbearing radiograph is not as effective as either of these WBCT measurements and only provides adequate diagnostic capability. Our results emphasize the value of diastasis measurements using bilateral WBCT imaging to diagnose Lisfranc instability. These results also suggest that diastasis measurements should be performed in the axial plane and on the dorsal aspect of the Lisfranc complex.

Can ChatGPT-4 Think Like an Orthopaedic Surgeon? Testing Clinical Judgement and Diagnostic Ability in Pathologies of the Foot and Ankle

Category: Other; Ankle Introduction/Purpose: Artificial intelligence chatbots have seen a notable rise in recent years, especially with the creation of ChatGPT, a chatbot that utilizes a language learning model with an ability to carry human-like conversation. While ChatGPT does not have any specific medicine-related training, prior studies have shown that its newest version, GPT-4, has been able to pass professional licensing examinations and perform comparably on question bank sets as surgical residents. The purpose of this study was to explore the diagnostic and decision-making capacities of ChatGPT-4 in clinical management specifically assessing for accuracy in identification and treatment of foot and ankle pathologies. Methods: This study presented 16 foot and ankle cases to ChatGPT-4. Each case was evaluated by 3 fellowship-trained foot and ankle orthopaedic surgeons. The scoring system included 5 criteria within a Likert scale, with 5 being the lowest score and 25 being the highest possible. The criteria included stating the correct diagnosis, stating the most appropriate procedure, identification of alternative treatments, providing comprehensive information beyond treatment, and not mentioning nonexisting therapies. ChatGPT-4 was referred to as “Dr. GPT”, using role prompting to encourage step-by-step processing and establish a peer dynamic so that the role of an orthopaedic surgeon was emulated by the chatbot. The 16 cases presented included the following: plantar fasciitis, Morton neuroma, ankle sprain, Achilles tendon rupture, Achilles tendonitis, metatarsalgia, peroneal tendon tear, posterior tibial tendon insufficiency, distal fibula fracture, 2nd metatarsal stress fracture, 5th metatarsal fracture, ankle arthritis, hallux rigidus, Lisfranc injury, midfoot arthritis, and hallux valgus. Results: The average score across all criteria for all 16 cases was 4.47, with an average sum score of 22.4. The plantar fasciitis case received the highest score, with an average sum score of 24.7. The lowest score was observed in the peroneal tendon tear case, with an average sum score of 16.3. Subgroup analyses of each of the 5 criterion using Friedman Rank Sum tests showed no statistically significant differences in surgeon grading. Criterion 5, lack of mention of nonexistent treatment options, and criterion 1, the ability for ChatGPT to correctly diagnose, received the highest subgroup scores of 4.88 and 4.77, respectively. The lowest criteria score was observed in criteria 4 (4.05), evaluating ChatGPT-4 providing comprehensive information beyond treatment options. Conclusion: This study demonstrates that ChatGPT-4 effectively diagnosed and provided reliable treatment for most foot and ankle cases presented, noting consistency amongst surgeon evaluators. The individual criterion assessment revealed that ChatGPT-4 was most effective in diagnosing pathologies. Additionally, the chatbot consistently did not suggest nonexistent treatment options, a common finding in prior studies evaluating ChatGPT-3.5 in which fabricated information was presented in a manner that was seemingly true. This resource could be useful for clinicians seeking patient education materials on diagnoses and treatment options without fear of incorrect information presentation, though comprehensive information beyond treatment may be limited.

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. Level of evidenceLevel 3 Therapeutic retrospective comparative study.

Hardware Removal after Lisfranc ORIF Results in Immediate Improvement in Physical Function

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Hardware removal (HWR) after Lisfranc open reduction internal fixation (ORIF) is often standard following successful treatment. The purpose of this study was to investigate whether HWR after Lisfranc ORIF resulted in immediate, measurable impact via PROMIS physical function (PF) and pain intensity (PI) scores. Methods: A retrospective review of all adult patients with surgically treated, isolated Lisfranc injuries at one tertiary level 1 trauma center between 2002-2023 was performed. Demographic data and patient reported outcomes (PROs) were recorded. Patients were excluded if they received index treatment other than ORIF, underwent secondary surgical intervention for their Lisfranc injury other than HWR, or if HWR did not occur in the standard 3-6 month interval following ORIF. Patients who underwent HWR and had PROMIS scores collected at their postoperative visit were compared to those with retained hardware by 6 months. The primary outcome was patient reported measures of PROMIS PF and PI. The Wilcoxon signed-rank test compared differences between PRO scores within the HWR removal group and the Wilcoxon ranked-sum test compared differences between HWR and no HWR groups. Distributive MCID was calculated using the 0.5 SD method. Results: We identified 482 patients (489 feet) with isolated Lisfranc injuries. Of these, seventy-seven feet underwent ORIF followed by HWR. Thirty feet had ORIF but did not have HWR. HWR occurred an average of 132 days (4.5 months) after ORIF. Patients who underwent HWR had a statistically significant increase in average PF scores in the immediate postoperative period, reaching the calculated MCID of 3.3 (40.2 to 45.6, p&lt; 0.001). HWR patients also had a non-significant decrease in average PI scores (55.9 to 54.2, p=0.103). Compared to those who did not undergo HWR, the HWR group demonstrated a statistically significant net improvement in PF scores from surgery, with an average improvement of 4.7 postoperatively (P=0.003). Conclusion: Patients experienced immediate and significant improvement in PROMIS PF scores after HWR for Lisfranc ORIF. HWR patients also had a non-significant decrease in average PROMIS PI scores.