Lisfranc Injuries Research Articles

Kinematic Analysis of Sequential Partial-Midfoot Arthrodesis in Simulated Gait Cadaver Model.

Primary tarsometatarsal (TMT) arthrodesis is gaining popularity in the surgical treatment of Lisfranc injuries. However, few studies have evaluated biomechanical effects of TMT arthrodesis. The purpose of this study was to compare the kinematics of joints adjacent to the midfoot during simulations of stance before and after sequential arthrodesis of the first, second, and third TMT joints. Ten midtibia cadaveric specimens were loaded on a 6-degree-of-freedom robotic gait simulator. Motion capture cameras were used to collect joint kinematics throughout simulations of the stance phase. Simulations were performed for the intact and sequential arthrodesis conditions of the first, second, and third TMT joints. The sagittal, coronal, and transverse plane rotational kinematics of the intact condition were compared to kinematics after each sequential arthrodesis condition. Sequential arthrodesis of the first and second TMT joints had no significant effect on ankle, subtalar, talonavicular, and first metatarsophalangeal joint motion during simulated stance when compared to the intact condition. In contrast, inclusion of the third TMT joint into the sequential arthrodesis significantly increased subtalar inversion (P = .032) in late stance and increased range of motion values in the ankle and subtalar joints by 2.1 degrees (P = .009) and 2.8 degrees (P = .014), respectively. Sequential primary arthrodesis induced changes to ankle and adjacent joint kinematics during stance phase simulations, although not until the third TMT joint was included into the primary arthrodesis. The significant changes to kinematics due to arthrodesis of the first, second, and third TMT joints were small. The minimal changes in sagittal, coronal, and transverse plane rotational kinematics support the positive clinical outcomes reported in the literature for primary partial arthrodesis of Lisfranc injuries. The inclusion of the third TMT joint should be done judiciously.

Defining Reference Values for the Normal Adult Lisfranc Joint Using Weightbearing Computed Tomography

The uninjured contralateral feet of consecutive patients undergoing cone-beam weightbearing computed tomography for acute Lisfranc injury between July 2017 and October 2019 were retrospectively analyzed. Of these, any cases with history or radiological evidence of trauma to the Lisfranc interval were excluded. The area of the non-weightbearing (NWBA) and weightbearing (WBA) Lisfranc joint was calculated (in mm2) using a novel technique. Area difference (AD) was calculated as WBA-NWBA. Area ratio (AR) was calculated as WBA/NWBA. A subset of cases was double-measured by 2 technologists to evaluate inter- and intraobserver variability. A total of 91 patients aged 15 to 74 years were included in the study. The measurement technique was reproducible with excellent intraobserver correlation (intraclass correlation coefficient [ICC]: 0.998, 95% confidence interval [CI]: 0.996-0.999) and high interobserver correlation (ICC: 0.964, CI: 0.939-0.979). The median NWBA was 83 (range 52-171) and median WBA was 86 (range 52-171). Median AD was 1 mm2 (range -3 to 10) and median AR was 1.01 (range 0.96-1.11). No significant difference was identified in AD or AR when adjusted for age, gender, patient-weight or weight put through the foot. Both AD and AR distributions were highly skewed toward 0 and 1, respectively. Based on 95% CI, normal reference range for AD is -1 to 7 mm2 and for AR is 0.98 to 1.09. Absolute area of the Lisfranc joint is highly variable between individuals. The Lisfranc joint is rigid with little to no physiologic widening in most subjects. The normal upper limit of widening of the Lisfranc area on weightbearing was 9%. Differences in age, sex, patient-weight or weight put through the foot were not significantly associated with the extent of joint widening.

Outcomes of Lisfranc Injuries in NCAA Football Players

Category: Sports; Midfoot/Forefoot Introduction/Purpose: While Lisfranc injuries are relatively infrequent, they are typically season-ending injuries for NCAA football players, and their impact on an athlete's future is poorly understood. In this study, we sought to define the rate of return to competition for NCAA Division I football players who sustained a Lisfranc injury, and analyze the effects on athletic performance and career outcomes. Methods: NCAA Division I football players who sustained Lisfranc injuries between 2012-2017 were identified and evaluated for their return to play in the season following their injury. Recorded demographic variables included position, class rank, and games played during the pre- and post-injury seasons. The underclassmen athletes who met performance criteria were then compared to matched, uninjured controls based on conference, position, age, and statistics. Career outcomes were evaluated for all athletes who sustained a Lisfranc injury based on whether they performed at the NFL Combine and/or played in at least 1 NFL game. Seniors were excluded from performance analysis because they did not have a post-injury NCAA season, but were included in career outcomes. Results: Sixty Lisfranc injuries were identified, 48 of which were sustained by underclassmen, who returned to play in the immediate post-injury season at a rate of 87.5%, and 95.8% returned at some point in their college careers. Of the players who met performance criteria, only quarterbacks showed statistically significant differences compared to controls for interceptions/game (p=0.0438), yet all positions experienced mild performance declines or stagnation across virtually all statistics, on average. However, 33.3% of athletes went on to perform at the NFL Combine, and 31.3% of athletes played in an NFL game, compared to 31.7% and 36.7%, respectively, for controls. Surprisingly, when evaluated separately, athletes who sustained a Lisfranc injury in their senior year had nearly identical career outcomes (Combine - 33.3%, NFL - 33.3%) compared to underclassmen. Conclusion: NCAA Division I football players return to play at a high rate following Lisfranc injuries, and largely maintain their athletic performance relative to uninjured controls. Moreover, Lisfranc injuries do not appear to have a significant impact on an athlete's ability to compete at an NFL-level.

Defining Operative Indications in Lisfranc Injuries

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Injuries to the midfoot, especially subtle, primarily ligamentous ones, have historically been under- recognized. The literature surrounding midfoot injuries has also evolved as understanding has improved. Earlier studies focused on non-subtle midfoot dislocations and fracture dislocations, injuries in which the need for operative intervention was perhaps obvious. However, in more subtle injuries, there is some lack of clarity amongst orthopaedic surgeons as to what constitutes an operative indication. The purpose of this study was to perform a literature review of Lisfranc injuries to answer the simple question of what the operative indication was in the given study. Methods: A literature search [MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases] was performed to identify studies on Lisfranc injuries. Given that the purpose was to assess surgical indications for Lisfranc injuries, all studies that included a surgical indication for Lisfranc injuries, including case reports and review articles, were included. Studies that were not relevant to that question (i.e. biomechanical studies, anatomic studies, etc.) were excluded. PRISMA guidelines were followed where applicable, although since this study did not involve the synthesis of outcome data, some aspects were not relevant. Studies were classified as having no operative indication, a vague operative indication, or an explicit operative indication. A vague operative indication is one that referenced displacement or instability without explicitly defining those terms, i.e. displacement between which bones (M1-M2, C1-M2, or otherwise) and to what degree (any displacement, >1mm, >2mm, or otherwise) with or without stress exam. Results: 737 studies were identified with the search term 'Lisfranc injury.' After review of the titles, 389 were felt to be potentially relevant to the question at hand. The papers were then reviewed to establish whether the indication for surgery was explicitly stated. We were unable to access 31 of these studies, and a further 51 were felt not to be relevant, leaving 307 studies that were assessed. 63.2% of these studies (194/307) did not give any specific indication for surgery. While 113 studies did give an indication for surgery, 59.3% of these studies (67/113) gave only a vague indication for surgery. Only 15.0% of studies assessed (46/307) had a clear, explicit operative indication. Conclusion: It is a basic tenet of any surgical discipline that one must understand what does and does not require surgery. The answering of this question perhaps becomes more difficult when the pathology is subtle and difficult to define. However, establishing clear guidelines is a necessity in this setting. There appears to be a relative lack of clear and explicit operative indications in the literature with respect to Lisfranc injuries. Surgeons and authors should be clear and consistent about which injuries require surgery; as we move forward, better outcome data will allow us to refine our indications.

Conservative Management of Lisfranc Injury: A Systematic Review

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries range from sprains to fracture-dislocations of the tarsometatarsal joints which include injury to the Lisfranc ligament complex. Most require surgical intervention. However, apparently stable injuries can be managed nonoperatively. The aims of the current study were to perform a systematic review of outcomes following nonoperative treatment of Lisfranc injuries. Methods: Following PRISMA guidelines and PROSPERO registered, a review was performed of the literature (2000 - 2021) reporting Lisfranc injuries considered to be stable and initially managed nonoperatively. Following exclusions, 8 papers were identified; 1 prospective and 7 retrospective studies. A total of 220 patients were studied with a mean age of 39.8 years and mean follow up of 4.3 years. Outcomes included function, displacement, rates of surgery and secondary osteoarthritis. Results: Four papers reported good outcomes, with adjusted functional scores ranging from of 82.6 to 100 (out of 100). However, poor outcomes were frequently reported. One paper reported that late displacement occurred in 54% of patients. Surgical intervention was required in 12.2 to 55.6% of patients. Rates of secondary osteoarthritis were 4.9 to 37.5%. Two papers directly compared operative to non-operative treatment. In an injury matched cohort, superior outcomes were reported in the surgical arm. Numerous limitations were identified, including a lack of consensus on what constitutes a stable injury. Furthermore, wide heterogeneity was identified due to use of different classification systems, PROMS, investigation modalities and treatment protocols. Conclusion: Reported outcomes following nonoperative treatment of Lisfranc injuries vary widely, including high rates of conversion to surgery. There is no agreed definition of what a stable Lisfranc injury is, and no agreed treatment protocol. With the advantage of modern imaging techniques, prospective research is needed to determine which Lisfranc injuries can be safely treated nonoperatively.

Augmented Stress Weightbearing CT for Evaluation of Subtle Lisfranc Injuries in the Elite Athlete

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The Lisfranc joint is the interface between the midfoot and forefoot and forms a strong connection due to its bony architecture and ligamentous attachments in the foot. An unstable Lisfranc injury has traditionally been defined as displacement >2 mm between the 1st and 2nd metatarsal bases or between the medial cuneiform and the second metatarsal base, when compared to the contralateral side on imaging modalities. Classically, Lisfranc injuries have been detected with standard X- ray, stress plain films, standard CT, MRI and ultrasound. We describe an imaging technique that may be used to further assist in the diagnosis and management of subtle Lisfranc injuries, and include a case to demonstrate its use in athletes. Methods: Cone beam weight bearing computed tomography (WBCT) is a well-described imaging modality for evaluation of foot and ankle injuries. We have found it highly beneficial to teach our CT technologists about Lisfranc injuries and the importance of augmented physiologic stress applied across the midfoot (in addition to the standard WBCT) to better demonstrate instability or motion, particularly at the second TMT joint. To perform an augmented stress weight bearing CT, the patient is positioned in the WBCT scanner and initial images are acquired in the standing weight bearing position with feet directed forward and weight distributed equally. A second image acquisition is then performed (augmented stress), where the patient is coached to lift both heels from the scanner platform symmetrically, in a calf-raise type exercise. It is important that the patient distributes weight as evenly as possible between the feet so the affected side is stressed sufficiently. Results: We present here a 22-year-old male collegiate football player who is an offensive lineman. While blocking during a game, his foot was plantarflexed, and he 'felt a pop' in his midfoot. On exam, the player was tender to palpation over the medial midfoot, at the Lisfranc joint. He had pain with forced pronation and abduction as well as axial load through the first webspace. Initial weight bearing radiographs did not show evidence of widening between the medial cuneiform and second metatarsal base. Due to his concerning examination, an MRI was ordered, which revealed a small bony avulsion off the plantar aspect of the second metatarsal base with an otherwise intact Lisfranc ligament. He then underwent weightbearing CT stress views of the foot, which revealed greater than 2 mm of widening between the first and second metatarsals when compared to the contralateral side, indicating instability of the Lisfranc joint. Conclusion: We present the augmented stress weightbearing CT technique of the midfoot to evaluate for subtle Lisfranc injury. The need for this imaging modality has proven useful in the elite athlete with subtle injury to the midfoot, otherwise not found on conventional imaging techniques. Timely diagnosis and treatment is imperiative to these players due to the morbidity associated with missed Lisfranc injuries. We propose this technique for diagnosing otherwise unrecognized, subtle Lisfranc injuries in patients where clinical suspicion persists despite negative imaging because this technique stresses the joint and we believe makes the weightbearing CT more sensitive for this injury.

Nitinol Shape Memory Staple Fixation of Lisfranc Fractures is Safe and Efficacious

Category: Trauma; Midfoot/Forefoot; Sports Introduction/Purpose: Surgical treatment of Lisfranc fractures has evolved from arthrodesis or transarticular screw fixation to joint preserving modalities (suture buttons and/or dorsal spanning plates), the latter commonly requiring removal due to metalwork irritation and to restore motion at the 1st-MTPJ. Shape memory staples formed from Nitinol exploit its biomechanical properties of; low Young's modulus, super elasticity and high ductility. To produce a robust implant that generates greater compressive forces at its distal end compared to traditional 316L stainless steel compression staples. Permitting the construction of a rigid fixation for Lisfranc fractures that is achieved with transarticular screws or plate fixation, but is mobile and elastic as with suture buttons. This study aims to assess the surgical outcomes of staple fixation in acute Lisfranc fractures. Methods: A prospective study to assess for union and necessity for revision surgery was completed for consecutive Lisfranc fractures treated with Nitinol shape memory staple fixation from June 2020 at a single U.K. Level 1 Major-Trauma-Centre. All operations were performed or supervised by a single fellowship trained Major Trauma Foot & Ankle Surgeon through a EHL bed approach to access the base of the 2nd MT and cuneiforms. Relevant joints were debrided and reduced, held with K-wires and reduction clamps to allow for the placement of the staples. A triangular configuration for the placement of three staples (2nd MT to Middle Cuneiform, 2nd MT to Medial Cuneiform, Middle to Medial Cuneiform). Reduction of the Lisfranc complex was confirmed on intra-operative fluoroscopy. Patients were non-weight bearing for 4 weeks with appropriate VTE prophylaxis. Staples were placed so as to not penetrate the plantar cortex and inter-cuneiform instability was assessed and confirmed intra- operatively. Results: Results from 19 consecutive patients were analysed, consisting of 9 men 10 women, with a mean age of 44 years (19-76). Seven patients sustained high energy trauma. Mean time to theatre was 18 days (5-28) from date of injury. Mean total operative time was 70 minutes, (27-154) with an mean tourniquet time of 63 minutes. An mean length of follow-up was 13.5-months (range 6-20 months), with a 100% union rate on weight-bearing radiographs and no incidences of post-operative complications requiring further medical or surgical intervention. No patients reported symptomatic implant irritation which required consideration of metalwork removal. The average FADI score was 73/104 (70%) at longest follow-up. Conclusion: Nitinol shape memory staple fixation of Lisfranc fractures is safe and efficacious, removing the necessity for metalwork removal as is commonly seen with dorsal bridging plates whilst maintaining the structural rigidity of plate/trans-articular screw fixation at the same time as allowing for physiological motion at the 1st-MTPJ. Patient reported outcome measures of this technique demonstrate equitable outcomes to more conventionally used techniques. This is the largest series of shape memory alloy staple fixation of acute Lisfranc injuries the authors are aware of and demonstrates that this technique should be considered a part of a surgeons' armamentarium when treated Lisfranc injuries.

Outcomes of Lisfranc Injuries Treated with Arthrex Internalbrace

Category: Midfoot/Forefoot Introduction/Purpose: Surgical treatment options for Lisfranc injuries include open reduction and internal fixation (ORIF) and primary arthrodesis. To date, various options of ORIF exist, including transarticular screws, dorsal plates, and more recently, flexible fixation methods such as suture button and InternalBrace (Arthrex Inc, Naples, FL).1-4 Flexible fixation techniques attempt to minimize post-surgical joint immobilization and prevent the articular cartilage damage seen with transarticular screws.4-6 Unlike other flexible fixation techniques, the InternalBrace avoids placement of a suture button on the medial cuneiform and prevents disruption of the tibialis anterior tendon.4,7 Patient outcomes have been reported for suture button and transarticular screw fixation; however, there is a lack of clinical data reported utilizing InternalBrace in Lisfranc injuries due to its recent FDA approval in 2019.1,2,4 Methods: A retrospective chart review was performed as part of a case study investigation of 9 patients who underwent ORIF with InternalBrace fixation by a single surgeon. Patients over 18 years of age were included. Results: The average follow-up time was 6.6 months (SD = 5.1 months). The average time to weight-bearing as tolerated was 6.8 weeks (n=9), while the average time to return to work/sport as tolerated was 14.3 weeks (n=7). The only complication noted at follow-up was hypersensitivity along the foot [1 (11%)] (Table 3). No hardware complications were noted at either 6-week and 12-week post-operative x-rays. Conclusion: In this retrospective chart review, the time to return to work/sport as tolerated was comparable to that of return to sport after ORIF with screws and combined bridge-plating (19.6 weeks) and suture button (19.4 weeks).8 Future research involving a larger cohort of patients is required and is currently being performed by our institution to further evaluate outcomes after use of the InternalBrace for Lisfranc injuries.

Factors Affecting Patient Reported Outcomes after Surgical Fixation of Lisfranc Injury

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The Lisfranc joint accounts for a small percentage of all fractures and is typically caused by trauma, high falls, or from athletic injuries. The treatment can be divided into operative and non-operative management based on the extent of the injury. Currently, as to the best of our knowledge, there is no literature that assesses patient reported outcomes after surgical intervention for Lisfranc injuries. This study provides an overview of the relationship between PROMIS scores and overall outcomes of patients who underwent surgical management for Lisfranc injury. Methods: A retrospective analysis was conducted for patients that underwent Lisfranc surgical repair at our facility from 2010- 2020. Using the electronic medical record (EMR), basic patient demographics, mechanism of injury, presence of rheumatoid arthritis, osteopenia/osteoporosis, time from injury to surgery, type of intervention utilized (ORIF, pinning, arthrodesis), use of bone grafting, and surgical complications were recorded. To evaluate outcomes, we used the Patient Reported Outcomes Measurement Information System (PROMIS) survey and Foot Function Index (FFI) scores. Results: A total of 248 patients met the criteria for our study with 80 participants completing both the PROMIS and FFI surveys. The average PROMIS physical function, pain interference, and depression scores were reported as 43.2, 55.4, and 45.4, respectively. The average FFI scores in this population are as follows: FFI pain- 37.1, FFI disability- 34.2, FFI activity limitation- 12.35, and the average FFI total score was 30.95. There was a significant decrease in postoperative pain scores when compared to preoperative pain from 5.23 to 1.85 (p=0.046). Complications were fairly low in this population with 4 patients experiencing surgical site infection, 36 patients described problematic hardware, and 45 patients underwent revisional surgery. Conclusion: Preliminary results suggest surgical intervention for Lisfranc injuries may be viewed as satisfactory amongst patients. Further analysis to compare patient reported outcomes based on the type of surgical intervention, hardware used for fixation, and whether any patient demographic factors have any influence on these outcomes are being conducted. Our fairly large patient population has a time from surgery date ranging from 1.5 years to 11.2 years. We believe further analysis will also provide quality information on the long-term outcomes regarding Lisfranc injuries

Functional Outcomes of Primary Arthrodesis vs Open Reduction and Internal Fixation in the Treatment of Lisfranc Injuries

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The lack of data regarding functional outcomes of midfoot primary arthrodesis (PA) and open reduction and internal fixation (ORIF) contributes to significant debate regarding the optimal method of treatment for Lisfranc injuries. Although PA is associated with lower rates of secondary procedure and posttraumatic arthritis, its impact on foot functionality has come into question due to sacrifice of tarsometatarsal (TMT) mobility. The authors hypothesize that there is no significant difference between patient recorded outcome measures (PROMs) among patients receiving PA and ORIF for the treatment of Lisfranc injuries. Methods: A retrospective cohort study of patients surgically treated for Lisfranc injuries between January 2010 and January 2019 at a Level I trauma center was undertaken. Retrospective chart review was utilized to obtain patient demographics, comorbidities, procedural information, complications, and additional treatments. Responding by survey, patients reported their functional competency in performing daily and sports-related activities via the validated Foot and Ankle Ability Measure (FAAM) instrument. For each patient, scores for the Activities of Daily Living (ADL) and Sports sections were calculated. Patients also reported their perceived current level of function on a percent scale with respect to functionality prior to TMT injury. Results: Twenty-four patients underwent PA, and 27 patients underwent ORIF. There were no significant differences between age (P=0.55), incidence of high energy injury mechanisms (P=0.14), comorbidities, or time to surgical intervention from injury (P=0.25) among PA and ORIF groups. There were no significant differences in FAAM scores among PA and ORIF groups. The average ADL scores for PA (72.42 +- 17.53) and ORIF (68.11 +- 28.24) were not significantly different (P=0.52), nor were the average Sports scores for PA (47.92 +- 25.48) and ORIF (48.56 +- 29.44) groups (P=0.94). However, patients in the PA group reported a significantly higher level of perceived ADL function (77.96% +- 17.97%) compared to patients in the ORIF group (60.04% +- 35.47%, P=0.03); this was not the case for perceived Sports functionality (P=0.67). Conclusion: This analysis of PROMs revealed no significant difference in the ability to participate in ADLs and sports between PA and ORIF groups. These results align with our hypothesis and suggest that despite sacrificing TMT joint mobility, functional outcomes of patients receiving PA were not significantly different from those receiving ORIF for Lisfranc injuries.

Tarsometatarsal Joint Preparation using a Modified Dorsal Approach vs Standard Approach: A Cadaver Study

Category: Midfoot/Forefoot Introduction/Purpose: Lisfranc injuries are a relatively common midfoot injury involving the tarsometatarsal (TMT) joint. Surgical fixation typically involves open reduction with internal fixation or primary arthrodesis of the joint(s). The standard surgical approach to the TMT joint involves two dorsal incisions however, a recent study has suggested the use of a modified single dorsal incision approach. The goal of this paper is to compare the total surface area of the joint that can be prepared for primary arthrodesis of the TMT using the standard vs modified single dorsal approach. Methods: Ten fresh frozen below-the-knee cadaver specimens were randomly assigned to receive either the standard or modified dorsal single incision operative approach to the TMT joint. Prior to initiating the study, specimens were inspected with fluoroscopic radiographs for preexisting pathology or prior surgical intervention. The joint surface was visualized and then underwent articular preparation as for a joint fusion. After adequate joint preparation, the TMT joint was disarticulated and the surface was photographed for image analysis. Using ImageJ, articular joint surface preparation areas were measured by two blinded reviewers. to assess the joint surface preparation and this was compared by surgical approach. Results: After ImageJ and Mann-Whitney U statistical analysis, there was no significant difference in the amount of joint prepared when comparing the standard versus modified dorsal approach for the first three TMT joints (p= 0.548, p=0.310, p= 0.548). The percentage of joint preparation utilizing the standard dorsal approach versus the modified dorsal approach for TMT joints one through three are as follows (percentages utilized are listed as the median value with its correlating range): First TMT- 67.6% (range 26%) by the standard approach versus 71.7% (range 9%) by the modified dorsal approach, second TMT- 67.9% (range 24%) versus 65.7% (range 12%), and third TMT- 65.9% (range 42%) versus 59.6% (range 24%). Table 1 summarizes our results between each operative approach. Conclusion: With our findings, we demonstrate that a modified single dorsal approach to the Lisfranc joint provided comparable joint preparation for primary arthrodesis as the standard dual incision approach. However, the modified dorsal approach may be beneficial in that it avoids creating a skin bridge which has potential for necrosis with the standard two incision approach. The authors believe the comparable joint preparation combined with its potential to alleviate soft tissue complications make the modified dorsal approach a viable surgical approach for a TMT arthrodesis.

Factors Affecting Patient Reported Outcomes after Surgical Fixation for a Lisfranc Injury

Category: Bunion; Other Introduction/Purpose: Hallux valgus is a common deformity the foot and ankle surgeon will encounter that tends to have a progressive nature with a predilection for females. There are many operative techniques to appropriately treat HV however, there is limited literature focused on patient-reported outcomes for these procedures. In particular, we intend to compare patient- reported outcomes for those who had early (2 weeks postoperatively) vs standard weight-bearing (SWB) (6 weeks postoperatively) postoperative protocols after hallux valgus correction via the Lapidus procedure. Methods: A retrospective analysis of patients that underwent hallux valgus correction at our facility from 2010-2021 was conducted. Patients were selected if they underwent this correction via the Lapidus procedure. Basic patient demographics, preoperative and post-operative hallux valgus angles and intermetatarsal angles were recorded, type of hardware used for fixation, postoperative weight bearing protocol, complication rate, deformity recurrence, duration of symptoms, and any adjunctive procedures were all recorded utilizing the electronic medical record. Early weight-bearing (EWB) was defined as beginning a protected weight-bearing protocol at the two week visit. To evaluate outcomes, we utilized the Foot and Ankle Ability Measure (FAAM) survey as well as the Patient Reported Outcomes Measurement Information System (PROMIS) survey. Results: A total of 77 patients met criteria for this study with 20 patients having completed both the FAAM and PROMIS score surveys. The average time point at which the outcomes were collected was 5.65 years postoperatively ranging from 2.43 to 11.5 years. There were 35 patients in the EWB cohort and 42 in the SWB protocol. The average PROMIS physical function, pain interference, and depression scores for the EWB population was 45.96, 54.66, and 47.48 respectively vs 47.10, 48.34, and 50.21 in the SWB group. Patients in the EWB group reported their average activities of daily living (ADLs) via the FAAM subscale to be at 57% vs 62% in the SWB group. For the FAAM Sports Subscale, both groups reported fairly low numbers at 44% and 36% respectively. In this study, 1 patient experienced wound infection, 3 patients experienced nonunion (2 EWB, 1 SWB), and 1 patient experienced deformity recurrence. Conclusion: Preliminary results suggest equivalent results for EWB and SWB postoperative protocol for patients undering the Lapidus procedure. We plan to increase the power of our study for a more thorough investigation as well as conduct a more intensive statistical analysis to gain more insight on patient related factors and their effect on outcomes. We expect a higher number of patients to complete the PROMIS and FAAM surveys as we continue to reach out to these patients.

Factors Influencing Postoperative Residual Diastasis after the Operative Treatment of Acute Lisfranc Fracture-Dislocation

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Clinically, surgeons may frequently encounter residual diastasis between the medial cuneiform and 2nd metatarsal base after the operative treatment of acute Lisfranc fracture-dislocations. The purpose of this study was to identify factors influencing postoperative residual diastasis. We specifically focused on the preoperative fracture pattern using 3- dimensional computed tomography (3D-CT). Methods: Radiographic and clinical findings of 66 patients who underwent operative treatment for acute Lisfranc fracture- dislocation were reviewed. Patients were grouped according to residual diastasis evaluated by weight-bearing anteroposterior radiograph of the foot at the final follow-up. Residual diastasis was defined as distance between the medial cuneiform and 2nd metatarsal base greater than the distance on the contralateral side by 2 mm or more. Demographic parameters and fracture patterns based on preoperative foot 3D-CT were compared. A paired t-test was used to compare continuous numeric parameters, while a chi-square test was used for the proportional parameters. Statistical significance was set at P-value less than 0.05 for all analyses. Results: The mean age at operation, sex, body mass index, and the rate of underlying diabetes were not significantly different between the two groups (P>0.05 each). Preoperative foot 3D-CT evaluation showed that the rate of large (>25% of 2nd tarsometatarsal joint involvement), displaced (>2 mm) fracture fragments on the plantar side of the 2nd metatarsal base was more pronounced in the group with residual diastasis (P=0.001), while medial wall avulsion of the 2nd metatarsal base was more frequent in the group without residual diastasis (P=0.001). Conclusion: While treating acute Lisfranc injuries, surgeons should be aware of the presence of a 2nd metatarsal base plantar fracture. A dorsoplantar inter-fragmentary fixation can be considered if the fragment is large and displaced.

Nitinol Staple vs Traditional Plate Osteosynthesis for Primary Arthrodesis of Lisfranc Injuries: A Retrospective Analysis

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Primary arthrodesis of Lisfranc and midfoot fracture-dislocations is a reliable treatment option, yet concerns remain about nonunion and dorsiflexion malunion. The use of a new generation of nitinol staples has proliferated in midfoot arthrodesis. The purpose of this study is to examine the use of nitinol staples in primary arthrodesis of acute Lisfranc fracture-dislocations, comparing outcomes to traditional plate and screw fixation. The primary hypothesis is that nonunion rates are lower with constructs that include nitinol staples than those with plates and screws alone. Secondary hypotheses are: 1. Total operative and tourniquet time are shorter using nitinol staples. 2. Reoperation rates are lower using nitinol staples. 3. Dorsiflexion malunion rates are lower using nitinol staples. 4. Functional outcome scores will indicate comparable post-arthrodesis disability. Methods: Midfoot fracture-dislocations treated with primary arthrodesis by seven foot and ankle orthopaedic surgeons at a tertiary referral center from 1/1/2012 to 8/1/2021 were reviewed. Patients with open fractures, fractures managed with external fixation, Charcot arthropathy, neuropathy, previous midfoot surgery, or concomitant hindfoot/ankle fractures were excluded. Of the 160 eligible patients, 121 met the required 4-month minimum radiographic follow-up. Preoperative imaging and operative records were reviewed, evaluating for associated metatarsal and cuneiform fractures, operative and tourniquet time, joints included, and fixation construct. Patients and individual joints (303 total) were categorized as either staples alone (47 patients), staples plus plates and screws (hybrid) (47), or plates and screws alone (35). Postoperative radiographs at last follow-up were then analyzed for union and malunion at each joint fused. CT scans were used, when available (41 patients), to assess for union. Medical records were reviewed for postoperative complications. FAAM, VR-12, and NPRS were collected. Results: When assessed at the individual joint level, the nonunion rate was higher (8%, 9/101) among joints fixed with plate and screw constructs than with hybrid (2.4%, 1/41) or staple only constructs (1.3%, 2/152) (P = 0.015). Of the 12 nonunions in the study, 6 had either a metatarsal or cuneiform fracture. Median OR and tourniquet time were both shorter for hybrid (92 & 83 minutes) and staple only (67 & 63 minutes) constructs than plate and screw only fixation (107 & 96 minutes) (P = 0.0002 & 0.0009). There were 17 (14%) reoperations including 10 hardware removals, 3 nonunion revisions, and 1 malunion revision. There was no difference in reoperation, malunion (14 total, 12%), or patient reported outcome measure between fixation types. Conclusion: Nitinol staples are effective in achieving bony fusion when used alone or in combination with plates and screws. With lower rates of nonunion and shorter tourniquet and operative time compared to traditional plate and screw fixation, their use should be considered for primary arthrodesis of Lisfranc and midfoot fracture-dislocations. Further studies are needed to determine if staples decrease the risk for dorsiflexion malunion and improve patient reported outcomes.

A Systematic Review of Outcomes Following Lisfranc Injury Fixation: Removal vs Retention of Metalwork.

Background:Following Lisfranc injury fixation, no consensus exists on whether to routinely remove metalwork. The aim of this study was to evaluate functional outcomes and complications in patients following routine removal of metalwork and in those with retained metalwork.Methods:A systematic review of literature (1999-2020) reporting results of metalwork removal vs retention following Lisfranc injury fixation, was undertaken. The primary outcome was functional outcomes at 1 year following index surgery. Secondary outcomes were rates of complications including unplanned removal of metalwork.Results:No studies directly comparing routine metalwork removal vs retention were found. A total of 28 studies reporting on 1069 patients were included. Of these, 10 studies (317 patients) reported on retention and 18 (752 patients) on routine removal of metalwork. The difference in the American Orthopaedic Foot & Ankle Society (AOFAS) score between removal and retention groups was 3.38 (95% CI 6.3-0.48), P = .02 (removal 79.97 [±16.09; 71-96]; retention 76.59 [±20.36; 65.4-94]). No difference in reported rates of infection was found between the 2 groups (0%-12% for both groups). Of the 317 patients in the retention group, metalwork was removed in 198 cases, resulting in a 62.5% unplanned removal rate.Conclusion:In conclusion, this systematic review found limited evidence comparing different strategies of metalwork management after Lisfranc injury fixation. A randomized controlled trial is necessary to elucidate if routine removal of metalwork confers any true benefit.Level of Evidence:Level IV, systematic review including case series.

Surgical controversies and current concepts in Lisfranc injuries.

Lisfranc injuries, not as rare as previously reported, range from ligamentous to complex fracture-dislocations. Anatomical studies have identified a complex of discrete structures, and defined the anatomical characteristics of the Lisfranc joint. A narrative evidence-based review encompassed and analyzed published systematic reviews. Outcomes included clinical and surgical decision-making, including clinical-presentation, diagnosis, pathological-assessment, surgical-management techniques and indications, post-surgical care and comparative outcomes. Better understanding of the Lisfranc complex anatomy aids surgical treatment and tactics. Prognosis is related to injury severity, estimated by the number of foot columns affected. Surgical outcome is determined by anatomical reduction for most fixation and fusion techniques. Appropriate treatment allows return to sport, improving outcome scores. Identification of Lisfranc injuries may be improved by imaging modalities such as weight-bearing computer tomography. Recent evidence supports dorsal plate fixation as a result of better quality of reduction. In complex injuries, the use of combined techniques such as trans-articular screw and plate fixation has been associated with poorer outcomes, and fusion may instead offer greater benefits. Open reduction is mandatory if closed reduction fails, highlighting the importance of understanding surgical anatomy. If anatomical reduction is achieved, acute arthrodesis is a safe alternative to open reduction internal fixation in selected patients, as demonstrated by comparable outcomes in subgroup analysis. The current controversies in surgical treatment remain around techniques and outcomes, as randomized controlled trials are infrequent.

Retrospective chart review: Weightbearing CT scans and the measurement of the Lisfranc ligamentous complex

BackgroundLisfranc Ligamentous Complex (LLC) injuries are commonly misdiagnosed due to their unreliable projection on plain films. Weightbearing CT (WBCT) scans are a relatively new imaging modality that has not yet been utilized to establish widely referenced baseline anatomic positions. MethodsA retrospective chart review was conducted of patients who had undergone weightbearing CT of the bilateral lower extremities with one-hundred and twelve being included (56 patients). Measurements of the Lisfranc joint were collected by two independent reviewers. Uninjured symmetric anatomy was used to describe a baseline for normal anatomic variation and to evaluate for sex-based or age-related differences. These measurements were then compared against the injured side. ResultsIn patients without Lisfranc injury, the 1st metatarsal base to 2nd metatarsal base distance (Base M1-M2) was 2.7 + /− 0.7 mm; 2nd metatarsal base to medial cuneiform (M2-C1) was 3.7 + /− 0.7 mm; intercuneiform distance was 1.2 + /− 0.3 mm; and sagittal descent 12.2 + /− 5.4 mm. Patients with injury to LLC had a larger M1-M2 base distance (Δ = 0.5903, p < 0.0001) and M2-C1 interval (Δ = 1.8008, p < 0.0001) compared to uninjured side. Males had significantly higher M2-C1 (p = 0.0031), intercuneiform distance (p = 0.0039), and sagittal descent (p = 0.0008) compared to female patients. No significant differences were found between left versus right side in any of the measurements. Intercuneiform distance (p = 0.0039) was found to significantly decrease as age increased, while sagittal descent significantly increased with increased age (p = 0.0066). ConclusionWeightbearing CT has high utility in identification of Lisfranc injuries particularly when comparing injured and uninjured sides, which may be its greatest utility in defining injuries. This is evident in the excellent diagnostic ability of the M2-C1 measurement. By defining baseline anatomic measurements for Lisfranc complex parameters in our patient population, we provide normal parameters for comparison when evaluating potential subtle injuries. Level of evidenceIII

Treatment Of Complex Open Lisfranc Injury In A Professional Bull Rider

HISTORY: An otherwise healthy 30-year-old male professional bull rider presented to our hospital as a transfer for an open left foot fracture after a bull stepped on his left foot during a professional competitive rodeo event. He immediately experienced pain in the affected foot. He denied any other injuries including trauma to the head or loss of consciousness. Although he has had multiple orthopedic injuries in the past, he denied any previous foot injuries to the left foot. PHYSICAL EXAMINATION: Physical examination revealed a large laceration on the medial aspect of the left foot over the 1st metatarsal with an open dislocation of the MT head. The open laceration site was 9 cm x 4 cm. The patient had mild loss of sensation and was unable to elicit movement in his toes. There was no trauma or tenderness present on the left hip, femur, knee or lower leg. DIFFERENTIAL DIAGNOSIS: 1. Open Lisfranc injury 2. Tarsometatarsal dislocation TEST AND RESULTS: Anterior-Posterior, lateral & oblique radiographs: 1. Complete dislocation of the first metatarsophalangeal joint 2. Lisfranc fracture/dislocation 3. Neck and base fractures of the second, third, and fourth metatarsals, base of fifth metatarsal 4. Cuboid fracture FINAL WORKING DIAGNOSIS: Open left first metatarsophalangeal dislocation and Lisfranc fracture-dislocation with multiple metatarsal fractures TREATMENT AND OUTCOMES: 1. Surgical irrigation & debridement of the wound, followed by open or closed fixation of fractures and dislocations. 2. Pin removal at 6 weeks post op and negative pressure wound therapy for 9 months postoperative. 3. Non-weight bearing for the first 8 weeks postoperative followed by progression to weight bearing as tolerated. 4. At 18 months post-operative, the patient was able to return to professional bull riding. 5. At 3.5 years from injury, there is residual pain and swelling present with development of hallux valgus. The foot/ankle is otherwise functioning appropriately and does not inhibit him from professional bull riding.

CT and Functional Outcomes of Primarily Ligamentous and Combined Ligamentous-Bony Lisfranc Injuries: A Retrospective Review

Lisfranc injuries have been rising in incidence and can cause significant and lasting morbidity. There is no consensus on the optimal surgical treatment for these injuries, be they primarily ligamentous or combined (bony and ligamentous). No study has ever followed Lisfranc injury patients postoperatively using advanced imaging. The purpose of this study was to compare the functional and radiographic outcomes of primarily ligamentous and combined osseous and ligamentous Lisfranc injuries treated operatively with reduction and fixation. We performed a retrospective review of all Lisfranc injuries treated operatively in a single institution over a 6-year period. Injuries were classified as primarily ligamentous or combined by independent evaluation of available computed tomography (CT) or magnetic resonance imaging. Outcomes were measured using the Short Musculoskeletal Function Assessment (SMFA). CT of 29 patients was performed at last follow-up to evaluate reduction and degenerative changes. Of the 56 patients identified, 38 were available for follow-up. The average follow-up was 3.8 years. There were 26 combined injuries and 12 primarily ligamentous injuries. Outcomes were excellent in all patients and there was no statistical difference in SMFA scores in any category between the groups. On follow-up CT, all injuries were anatomically reduced, and 26 of 29 patients had degenerative changes. Our results support that reduction and stable fixation of Lisfranc injuries may be suitable treatment regardless of classification as combined or primarily ligamentous. Future larger-scale prospective studies should be pursued to supplement existing data.

Biomechanical Comparison of Fiber Tape Device Versus Transarticular Screws for Ligamentous Lisfranc Injury in a Cadaveric Model

Background: The preferred method of fixation and surgical treatment for ligamentous Lisfranc injuries is controversial. Transarticular screws, bridge plating, fusion, and flexible fixation have been described, yet none have demonstrated superiority. Furthermore, screw fixation and plating often require secondary surgery to remove implants, leading surgeons to seek alternative fixation methods. Purpose: To compare transarticular screws and a fiber tape construct under a spectrum of biomechanical loads by evaluating the diastasis at 3 joints in the Lisfranc complex. Study Design: Controlled laboratory study. Methods: Eight matched pairs of fresh, previously frozen lower extremity cadaveric specimens were fixed with either 2 cannulated transarticular crossed screws or a fiber tape construct with a supplemental intercuneiform limb. The diastasis between bones was measured at 3 midfoot joints in the Lisfranc complex: the Lisfranc articulation, the second tarsometatarsal joint, and the intercuneiform joint. Measurements were obtained for the preinjured, injured, and fixation conditions under static loading at 50% donor body weight. Specimens then underwent cyclic loading performed at 1 Hz and 100 cycles, based on 100-N stepwise increases in ground-reaction force from 100 to 2000 N, to simulate postoperative loading from the partial weightbearing stage to high-energy activities. Failure of fixation was defined as diastasis ≥2 mm at the Lisfranc articulation (second metatarsal–medial cuneiform joint). Results: There were no significant differences in diastasis detected at the Lisfranc articulation or the intercuneiform joint throughout all loading cycles between groups. All specimens endured loading up to 50% body weight + 1400 N. Up to and including this stage, there were 2 failures in the cannulated transarticular crossed-screw group and none in the fiber tape group. Conclusion: The fiber tape construct with a supplemental intercuneiform limb, which does not require later removal, may provide comparable biomechanical stability to cannulated transarticular crossed screws, even at higher loads. Clinical Relevance: Ligamentous Lisfranc injuries are common among athletes. Therefore, biomechanical evaluations are necessary to determine stable constructs that can limit the time to return to play. This study compares the biomechanical stability of 2 methods of fixation for ligamentous injury through a wide spectrum of loading, including those experienced by athletes.