Lisfranc Injuries Research Articles

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.

Midtarsal 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. All CBCT studies performed due to (TAAFI) that had previous XR were collected for a period of 5years. They were retrospectively anonymized and analyzed by a radiologist. A second blinded study of XR was made by a second radiologist as a control. A 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). This 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.

Hardware Removal After Lisfranc ORIF Results in Improved Physical Function.

The purpose of this study was to investigate whether HWR after Lisfranc ORIF resulted in significant impact via PROMIS physical function (PF) and pain intensity (PI) scores. Design: Retrospective cohort. Level-1 trauma center. Adult patients with isolated Lisfranc injuries who were treated via ORIF between 2002-2023 that had PROMIS PF and PI scores through 6 months follow-up were included. Patients were excluded if they received index treatment other than ORIF or underwent secondary surgical intervention prior to HWR. A sub analysis was performed at 1 year follow- up. Primary outcomes were PROMIS PF and PI scores. The Wilcoxon signed-rank test compared differences between PROMIS scores within the HWR group. The Wilcoxon ranked-sum test compared differences between HWR vs no HWR. Distributive MCID was calculated using the 0.5 SD method. There were 482 patients (489 feet) identified with isolated Lisfranc injuries. Seventy-seven feet underwent ORIF followed by HWR. Thirty feet underwent ORIF without HWR. The average age of the no HWR group was 45.8 (18.0-81.3) versus the HWR group which was 38.7 (18.3-74.1) (p=0.053). Nineteen (63.3%) were female in the no HWR group compared to 33 (42.9%) in the HWR group (p=0.084). HWR occurred an average of 4.43 months after ORIF. Patients who underwent HWR had a statistically significant increase in average PF scores (39.7 to 45.9, p<0.001) at their standard 6 week (1.5 month) postoperative visit. HWR patients had a non-significant decrease in average PI scores (56.5 to 53.9, p=0.24). Compared to those with retained hardware, the HWR group demonstrated a statistically significant net improvement in PF and PI scores from surgery, with an average improvement of 5.6 and 1.7, respectively (P=0.002, 0.008). Patients experienced significant improvement in PROMIS PF scores for Lisfranc ORIF at 6 weeks after HWR. Compared to patients with retained hardware, they also experienced significant improvement in PROMIS PF and PI scores. III.

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.

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.

Lisfranc Injury: A Case Report and Literature Review

Lisfranc injuries are relatively rare, accounting for only 0.2% of all injuries, and few case reports have been published on this topic. In this report, we present a case of a Lisfranc injury in a healthy 30-year-old male who fell down a staircase, landing on his left foot. The diagnosis was made using X-rays and computed tomography (CT). The X-rays showed dislocation of the tarsometatarsal joint with lateral displacement of the M4, M3, M2, and M1 metatarsals. The CT scan revealed a fracture-dislocation of the second metatarsal, with detachment of intra- and extra-articular bone fragments associated with a fracture of the medial cuneiform bone. Surgical management, in the form of open reduction and internal fixation, was performed. The patient followed an expected postoperative course and was doing well, without pain or limitation of activities, at his 3-month postoperative visit. Additionally, we provide a brief review of similar published cases and an overview of Lisfranc injuries.

The utility of point-of-care dynamic ultrasonography for the diagnosis of subtle isolated ligamentous Lisfranc injuries: a cadaveric study.

To assess if Lisfranc injury can be detected by US with and without abduction stress. Eight cadaveric feet were obtained. The following measurements were obtained in the uninjured feet: C1M2 and C1C2 intervals and TMT1 and TMT2 dorsal step-off distances. Measurements were obtained both with and without abduction stress using ultrasound. The injury model was created by transecting the Lisfranc ligament complex, after which the observers performed the measurements again. Statistical analysis was used to identify differences between intact and injured models, to determine diagnostic cut-off values for identifying Lisfranc injuries, and to assess interobserver/intraobserver reliability. There was a significant difference in the mean C1M2 interval, both with and without abduction stress, between the intact and torn Lisfranc ligament (p < 0.001). A C1M2 interval with stress of > 2.03mm yielded 81% sensitivity and 72% specificity for Lisfranc disruption. There was no significant difference in the mean C1C2 interval of the torn versus intact Lisfranc ligament without stress (p = 0.10); however, the distance was significantly different with the application of stress (p < 0.001). The C1C2 interval of > 1.78mm yielded 72% sensitivity and 69% specificity for Lisfranc injury under stress. There were no significant differences in the mean TMT1 or TMT2 dorsal step-off measurements between the intact and torn Lisfranc ligaments. All observers showed good intraobserver ICCs. The interobserver ICCs for all measurements were good or excellent, except for TMT1, which was moderate. Ultrasonography is a promising point-of-care imaging tool to detect Lisfranc ligamentous injuries when measuring C1M2 and C1C2 distances under abduction stress.

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

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. 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. 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. 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. 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.

Weightbearing Computed Tomography Can Accurately Detect Subtle Lisfranc Injury.

Early detection of Lisfranc injury is critical for improving clinical outcomes, but diagnosing subtle injury can be difficult. Weightbearing computed tomography (WBCT) allows evaluation of such injuries in 3 dimensions (3D) under physiologic load. This study aimed to assess the utility of 1-, 2-, and 3-dimensional measurements on WBCT to diagnose subtle injury in isolated ligamentous Lisfranc injuries. Ten cadaveric specimens underwent WBCT evaluation of the Lisfranc joint complex in the intact state and subsequently with sequential sectioning of the dorsal Lisfranc ligament and interosseous Lisfranc ligament (IOL) to create subtle Lisfranc injury, and finally after transectioning of plantar Lisfranc ligament (PLL) to create the injury conditions for complete ligamentous Lisfranc injury. Measurements under static vertical tibial load of 80 kg were performed on WBCT images including (1) Lisfranc joint (medial cuneiform-base of second metatarsal) volume, (2) Lisfranc joint area, (3) C1-C2 intercuneiform area, (4) C1-M2 distance, (5) C1-C2 distance, (6) M1-M2 intermetatarsal distance, (7) first tarsometatarsal (TMT1) alignment, (8) second tarsometatarsal (TMT2) alignment, (9) TMT1 dorsal step-off distance, and (10) TMT2 dorsal step-off distance. In the subtle Lisfranc injury state, Lisfranc joint volume and area, C1-M2 distance, and M1-M2 distance measurements on WBCT significantly increased, when compared with the intact state (P values .001 to .014). Additionally, Lisfranc joint volume and area, C1-M2 distance, M1-M2 distance, TMT2 alignment, and TMT2 dorsal step-off measurements were increased in the complete Lisfranc injury state. Of all measurements, C1-M2 distance had the largest area under the curve (AUC) of 0.96 (sensitivity = 90%; specificity = 90%), followed by Lisfranc volume (AUC = 0.90; sensitivity = 80%; specificity = 80%) and Lisfranc area (AUC = 0.89; sensitivity = 80%; specificity = 100%). In a cadaveric model we found that WBCT scan can increase the diagnostic accuracy for subtle Lisfranc injury. Among the measurements, C1-M2 distance exhibited the highest level of accuracy. The 2D joint area and 3D joint volume also proved to be accurate, with 3D volume measurements of the Lisfranc joint displaying the most significant absolute difference between the intact state and increasing severity of Lisfranc injury. These findings suggest that 2D joint area and 3D joint volume may have potential as supplementary measurements to more accurately diagnose subtle Lisfranc injuries. WBCT may help surgeons detect subtle Lisfranc injuries.

Lisfranc injuries

Lisfranc injuries are rare but severe injuries of the foot. They range from ligament sprain to complex fracture dislocations. Etiologically, adistinction is made between indirect and direct force and between high-energy and low-energy trauma. Inadequate diagnostics (injuries overlooked or misinterpreted) can lead to painful posttraumatic osteoarthritis, chronic instability and deformity of the foot. Afracture, malalignment and unclear findings in conventional radiological diagnostics necessitate computed tomography imaging including 3D reconstruction. Lisfranc injuries are often associated with accompanying pathologies of the foot that also need to be addressed. Only stable non-displaced fractures can be treated conservatively. Depending on the injury pattern, surgical treatment is performed percutaneously, minimally invasive or open. The prognosis following Lisfranc injury is determined by the severity of damage and the quality of reconstruction.

Delayed Diagnosis of a Ligamentous Lisfranc Injury on a Bomber Task Force Member.

The tarsometatarsal joint, or Lisfranc joint, is an extremely important anatomical structure and injury to it has been shown to cause long-term disabling ramifications. With a wide spectrum of injury involvement, from fracture dislocations to sprains, it is important to establish a diagnosis early to guide management. Although the more extreme higher energy fracture dislocations are more widely studied, there remains a paucity of literature on lower energy purely ligamentous injuries, especially among military service members.1 The deployed setting provides an extra layer of complexity in determining a musculoskeletal injury etiology for the provider, especially in resource-limited areas. When a high level of suspicion for Lisfranc injury exists based upon clinical presentation and in the setting of negative X-rays, more prudence should be placed on additional workup. This will guide decision-making for possible expedited stateside return for the patient and better odds of follow-up care. The following case demonstrates a unique scenario of an undiagnosed, purely ligamentous Lisfranc tear in a 23-year-old woman in a deployed environment with late presentation to an orthopedic surgeon stateside. Furthermore, emphasis is placed on factors that led to her delayed diagnosis and how advocating for advanced imaging modalities up-front can expedite care.

EVALUATING THE UTILITY OF PLAIN RADIOGRAPH AND COMPUTERIZED TOMOGRAPHY SCANNING IN IDENTIFYING CONCOMITANT FOOT FRACTURES IN PATIENTS WITH UNSTABLE LISFRANC INJURIES

BackgroundLisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification.MethodsA retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures.ResultsA total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p&lt;0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p&lt;0.001), third metatarsal (37% vs 61%, p&lt;0.001) and fourth metatarsal (26% vs 43%, p&lt;0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%).ConclusionFrom our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning.

FUNCTIONAL OUTCOMES OF DORSAL BRIDGE PLATING FOR LISFRANC INJURIES WITH ROUTINE METALWORK RETENTION: A MAJOR TRAUMA CENTRE EXPERIENCE

BackgroundAnatomical reduction of unstable Lisfranc injuries is crucial. Evidence as to the best methods of surgical stabilization remains sparse, with small patient numbers a particular issue. Dorsal bridge plating offers rigid stability and joint preservation.The primary aim of this study was to assess the medium-term functional outcomes for patients treated with this technique at our centre. Additionally, we review for risk factors that influence outcomes.Methods85 patients who underwent open reduction and dorsal bridge plate fixation of unstable Lisfranc injuries between January 2014 and January 2019 were identified. Metalwork was not routinely removed. A retrospective review of case notes was conducted. The Manchester-Oxford Foot Questionnaire summary index (MOXFQ-Index) was the primary outcome measure, collected at final follow-up, with a minimum follow-up of 24 months. The American Orthopedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause re-operation rates were secondary outcome measures. Univariate and multivariate analyses were used to identify risk factors associated with poorer outcomes.ResultsMean follow-up 40.8 months (24–72). Mean MOXFQ-Index 27.0 (SD 7.1). Mean AOFAS score 72.6 (SD 11.6). 48/85 patients had injury patterns that included an intra-articular fracture and this was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both p &lt; 0.001). 18 patients (21%) required the removal of metalwork for either prominence or stiffness. Female patients were more likely to require metalwork removal (OR 3.89, 95% CI 1.27 to 12.0, p = 0.02). Eight patients (9%) required secondary arthrodesis.ConclusionsThis is the largest series of Lisfranc injuries treated with dorsal bridge plate fixation reported to date and the only to routinely retain metalwork. The technique is safe and effective. The presence of an intraarticular fracture is a poor prognostic indicator. Metalwork removal is more likely to be needed in female patients but routine removal may not be essential.

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

IntroductionLisfranc 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 methodsThis 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. ResultsAn 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. DiscussionContrary 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.

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.

The Use of Knotless Suture Tape Construct vs Screw Fixation for Lisfranc Injuries: A Cadaveric Biomechanical Study.

Lisfranc injuries are often treated with open reduction and internal fixation using rigid fixation techniques. The use of flexible fixation to stabilize the Lisfranc joint is a newer technique. The purpose of this cadaveric study is to compare the amount of diastasis at the Lisfranc interval under diminished physiologic loads when treated with a knotless suture tape construct and a solid screw. Ten cadavers (20 feet) had native motion at the intact Lisfranc interval assessed at multiple increasing loads (69, 138, and 207 N). The Lisfranc ligamentous complex was then disrupted, and testing repeated to evaluate the amount of diastasis. Randomization was performed to determine the type of fixation for each cadaver: solid screw or knotless suture tape construct. Once fixation was completed, specimens were cyclically loaded for 10 000 cycles at loads, and diastasis was quantified after each load cycle to compare the interventions. Diastasis was measured using motion tracking cameras and retroreflective marker sets. A non-inferiority statistical analysis was performed. Diastasis mean values were confirmed to be >2 mm for all load bearing conditions in the injury model. Posttreatment, diastasis was significantly reduced when compared to the sectioned conditions (P < .01) for both treatment options. Non-inferiority analyses showed that the knotless suture tape construct did not perform inferior to screw fixation for diastasis at the Lisfranc interval at any of the compared load states. Under the loads tested, there is no significant difference in diastasis at the Lisfranc interval when treating ligamentous Lisfranc injuries with a knotless suture tape construct or solid screws. Both reduced diastasis from the injured state and were not different from the intact state. In this cadaveric model with ligamentous Lisfranc injury, diastasis of a knotless suture tape construct is compared to solid screw fixation as tested.

Investigation of subtle Lisfranc injuries using weight-bearing computed tomography

Introduction: Lisfranc ligamentous injuries are common yet remain a diagnostic challenge. Automated analysis of weight-bearingcomputed tomography (WBCT) images has been investigated to diagnose various pathologies. However, it has not been studied forLisfranc ligament injuries. The objective of the study was to examine whether automated WBCT analysis could demonstrate diagnosticutility for these injuries. Methods: Serial sectioning of Lisfranc complex ligaments was conducted on 24 cadaveric limbs to simulate Lisfranc injuries. WBCT images were collected at each dissection condition under three loading conditions. Images were automatically segmented, and automated measures of specific angles and distances in the midfoot were calculated using digitally reconstructed radiographs. These were analyzed using repeated measures ANOVA and paired T-tests to identify significant differences between dissections at each loading condition. Results: Overall, minimal differences between dissection conditions were observed in automatically generated measures. Differences in axial angles of the metatarsals in severe dissections were observed, and there were fewer differences in angular measures across dissection conditions in fully loaded than unloaded conditions. Conclusions: Automated analysis of WBCT images may indicate severe Lisfranc ligamentous injury but is insufficient to diagnose ligament injuries without full capsule disruption. This lack of injury markers may be due to the imaging conditions, automated analysis, or biomechanics of Lisfranc injuries. More alignment differences were seen under unloaded conditions, suggesting that weight-bearing imaging may not be appropriate for this injury. Overall, automated analysis shows only minimal changes in alignment measures, and additional study is necessary to improve diagnostic tools for Lisfranc injuries. Evidence Level V; Mechanism-based reasoning.

THE NATURAL HISTORY OF UNDISPLACED LISFRANC-TYPE INJURIES INITIALLY TREATED CONSERVATIVELY

BackgroundUndisplaced Lisfranc-type injuries are subtle but potentially unstable fracture-dislocations with little known about the natural history. These injuries are often initially managed conservatively due to lack of initial displacement and uncertainty regarding subsequent instability at the tarsometatarsal joints (TMTJ). The aim of this study was to determine the secondary displacement rate and the need for delayed operative intervention in undisplaced Lisfranc injuries that were managed conservatively at initial presentation.MethodsOver a 6-year period (2011 to 2017), we identified 24 consecutive patients presenting to a university teaching hospital with a diagnosis of an undisplaced Lisfranc-type injury that was initially managed conservatively. Pre-operative radiographs were reviewed to confirm the undisplaced nature of the injury (defined as a diastasis&lt; 2mm at the second TMTJ). The presence of a ‘fleck’ sign (small bony avulsion of the second metatarsal) was also noted. Electronic patient records and sequential imaging (plain radiographs/CT/MRI) were scrutinized for demographics, mechanism of injury and eventual outcome.ResultsThe mean age of the patients at the time of injury was 42 years (19 Female). 96% (23/24) were low energy injuries and 88% (21/24) had a positive ‘fleck sign’. The secondary displacement rate in this group of patients was 62.5% (15/24) over a median interval of 14 days (range 0 to 482 days). 12 patients underwent open reduction internal fixation after a median interval of 29 days (range 1 to 294 days) from their initial injury. One patient required TMTJ fusion at 19 months and two patients were managed non-operatively. The injury remained undisplaced in 37.5% patients (9/24) with only one patient requiring subsequent TMTJ fusion at 5 months.ConclusionUndisplaced Lisfranc injuries have a high rate of secondary displacement and warrant close follow-up. Early primary stabilisation of undisplaced Lisfranc injuries should be considered to prevent unnecessary delays in surgical treatment.