Ligamentous Lisfranc Injuries Research Articles

Biomechanical Comparison of FiberTape Device Repair Techniques of Ligamentous Lisfranc Injury in Cadaveric Model

Category:Trauma; Basic Sciences/Biologics; Midfoot/Forefoot; SportsIntroduction/Purpose:Lisfranc ligamentous injuries are complex. Controversy exists regarding their treatment and preferred method of fixation. Fixation methods employing a FiberTape device and interference screw fixation have been described as an alternative to traditional screw fixation. The purpose of this biomechanical study was to evaluate two methods of fixation utilizing interference screw fixation with FiberTape augmentation in a cadaveric model.Methods:9 paired cadaveric feet (mid tibia/fibula) were separated into two groups based on fixation method: FiberTape alone and FiberTape with supplementary limb into the middle cuneiform via anchor. At three joints of the midfoot (second metatarsal - medial cuneiform, intermediate cuneiform - medial cuneiform, second metatarsal - intermediate cuneiform), the diastasis and relative angular displacement between bones in the coronal plane were measured for static and cyclic loading. Measurements were obtained for the native (pre-injured), injured, and post-fixation in static loading. Fixed specimens then underwent stepwise increases in cyclic loading performed at 1 Hz and 100 cycles, at 100 N intervals from 500 to 1800 N ground reaction force. The Achilles tendon was also loaded to simulate postoperative weightbearing. Failure of fixation was defined as diastasis at the second metatarsal - medial cuneiform joint greater than 2 millimeters.Results:FiberTape specimens demonstrated diastasis failures of 3 of 9 (33%) specimens at cyclic loads of 1000 N. Conversely, FiberTape with supplementary limb specimens all survived past this loading magnitude, with 1 failing at supraphysiologic loads (>1200 N). The difference in diastasis at the second metatarsal-medial cuneiform joint was statistically significant between the two groups at forces of 1600N (p = 0.019) and 1800N (p = 0.029). There were no significant differences between the other joint diastases and relative angular displacements.Conclusion:The use of FiberTape for fixation of ligamentous Lisfranc injuries appears to provide a biomechanically viable alternative for withstanding early post-operative protected weightbearing. Furthermore, the use of a supplementary limb in addition to the FiberTape fixation method appears to enhance its biomechanical efficacy under cyclic loading especially at higher loads.

Change in the First Cuneiform-Second Metatarsal Distance After Simulated Ligamentous Lisfranc Injury Evaluated by Weightbearing CT Scans.

This study aimed to investigate the widening between the first cuneiform (C1) and second metatarsal (M2) in a Lisfranc ligamentous complex (LLC) joint injury model subjected to successive ligament dissections evaluated by weightbearing computed tomography (CT) scans. Twenty-four intact cadaveric feet served as the control (condition 1). Each component of the LLC (dorsal, interosseous, and plantar ligaments-conditions 2, 3, and 4, respectively) were then sequentially dissected. The specimens were equally randomized to 1 of 3 additional dissections (first or second tarsometatarsal [TMT] joint capsule or first-second intercuneiform ligament [ICL]-conditions 5a, 5b, and 5c, respectively). One additional ligament was then randomly transected (eg, condition 6ac-transection of the first TMT capsule and ICL). Finally, the remaining ligament was transected (condition 7). After each dissection, CT scans were acquired under nonweightbearing (NWB, 0 kg), partial-weightbearing (PWB, 40 kg), and full-weightbearing (FWB, 80 kg) conditions. The distance between the lateral border of C1 and the medial border of M2 was assessed to evaluate diastasis. Linear regressions with 95% CIs and converted q values were used to compare the measured data. No significant differences were found within the control. In condition 4, an average axial plane widening relative to control of 1.6 mm (95% CI, 1.5-1.8) and 2.1 mm (95% CI, 1.9-2.2) was observed under PWB and FWB. A coronal plane widening of 1.5 mm (95% CI, 1.3-1.6) and 1.9 mm (95% CI, 1.7-2.1) under PWB and FWB, respectively, was measured. A 95% CI of at least a 2-mm widening during PWB was demonstrated in 5c, 6ac, 6bc, and 7. Weightbearing computed tomography (WBCT) scans were used to detect ligamentous Lisfranc injuries in a cadaveric model. Relative axial widening greater than 1.5 mm under PWB conditions could indicate a complete LLC injury. Complete transection of the intercuneiform 1-2 ligament was required to detect a 2-mm widening in the nonweightbearing condition. This study provides insight on the detection of various severities of LLC injuries using WBCT imaging.

Not to Be Missed: Subtle Radiographic Findings of the Ligamentous Lisfranc Injury.

Not to Be Missed: Subtle Radiographic Findings of the Ligamentous Lisfranc Injury.

Asymmetric lambda sign of the second tarsometatarsal joint on axial weight-bearing cone-beam CT scans of the foot: preliminary investigation for diagnosis of subtle ligamentous Lisfranc injuries in a cadaveric model.

Subtle Lisfranc joint injuries remain challenging to diagnose. Although of questionable accuracy, the current gold standard to assess these injuries is through bilateral weight-bearing radiography. However, weight-bearing cone beam-computed tomography (CBCT), providing clearer visualization of bony landmarks, can also be utilized for evaluation. This study aims to establish the hypothesis that a specific weight-bearing CBCT finding (asymmetric lambda sign) can serve as an independent indicator of a subtle Lisfranc injury. Weight-bearing CBCT images of 24 match-paired cadaveric legs were acquired, initially intact, and then following sequential dissection of each aspect (dorsal, interosseous, and plantar ligaments, respectively) of the Lisfranc ligamentous complex (LLC). All scans were taken in non- (NWB, 0kg), partial- (PWB, 40kg), and full-weight-bearing (FWB, 80kg) manners. The lambda sign was then inspected axially for asymmetry (positive sign) by identifying three symmetrical joint spaces created between the medial cuneiform and the second metatarsal base (C1-M2), the medial and middle cuneiform (C1-C2), and the second metatarsal base and middle cuneiform (M2-C2). A positive sign was observed in 25.6% (221/864) of all studies. Most notably, the fully dissected specimens demonstrated an asymmetric lambda sign in 33.3%, 72.2%, and 83.3% in NWB, PWB, and FWB conditions, respectively. The inter- and intra-observer reliability kappa value was calculated to be 0.843 and 0.912. An asymmetric lambda sign is a simple and useful indicator for a complete LLC injury in PWB and FWB conditions using a cadaver model.

Change in the C1-M2 Distance after Simulated Purely Ligamentous Lisfranc Injury as Evaluated by Weightbearing CT Scans: A Match-Paired Cadaveric Study

Category:Trauma; Midfoot/ForefootIntroduction/Purpose:Introduction: The incidence of Lisfranc injury is higher than previously estimated, and more than two- thirds of these injuries are caused by low-energy trauma. This low-energy mechanism, common to the athletic population, tends to be distinctly characterized by a primarily ligamentous Lisfranc injury. Bilateral weightbearing radiographs are widely accepted as the gold standard and are able to diagnose instability by contralateral comparison. However, contrary to radiography, CT imaging is not obscured by metatarsals overlapping each other and their adjacent tarsal bone and thus provides a better visualization of bony structure. This study’s purpose was to model a purely ligamentous Lisfranc joint injury to determine widening between the medial cuneiform (C1) and second metatarsal (M2) after each ligament dissection under non-weightbearing (NWB, 0 kg), partial weightbearing (PWB, 40 kgs.), and full weightbearing (FWB, 80 kgs.) conditions evaluated by weightbearing computed tomography (WBCT).Methods:Methods: Twelve paired through-knee cadavers were incised dorsally to visualize the Lisfranc joint complex. An intact ligament condition was the control (group 1). The dorsal ligament (group 2), interosseous ligament (group 3), and plantar ligament (group 4) were sequentially dissected. The twelve pairs were then equally randomized (groups 5a, 5b, and 5c). The first tarsometatarsal joint capsule (group 5a), the second tarsometatarsal joint capsule (group 5b), or the intercuneiform ligament (group 5c) was transected. The remaining intact ligaments of each subgroup were similarly randomized for transection (e.g., group 6ac: transection of the first tarsometatarsal joint, followed by transection of the intercuneiform ligament). Finally, the last ligament was transected (group 7). After each dissection, CT scans were taken for NWB, PWB, and FWB conditions. Distance between the lateral border of C1 and the medial border of M2 was used to evaluate diastasis for both coronal and axial views. Analysis of variance (ANOVA) tested for significant differences between all groups. Dependent t-test evaluated for significance of the weightbearing variable.Results:In group 1, C1-M2 distance was 3.9 mm (3.5-4.3, SD 0.3) for coronal imaging and 4.0 mm (3.6-4.5, SD 0.4) for axial imaging, and no statistically significant differences were found between paired feet (P = 0.61) or for weightbearing conditions (P = 0.34). In group 4, an average widening of 1.4-mm (0.8-2.1 mm, SD 0.4) and 1.8-mm (1.4-2.8 mm, SD 0.5) were observed for PWB and FWB in the coronal view, and an average widening of 1.5-mm (0.9-2.3 mm, SD 0.5) and 2.0-mm (1.4-3.0 mm, SD 0.5) were observed for PWB and FWB in the axial view, respectively. For the subsets of group 5, only 5c was found to have a majority of specimen (7/8, 87.5%) that had significant widening - at least 2 mm - between C1-M2 for the PWB condition in the axial view; for the FWB condition, significant widening was found in both the axial and coronal view. In groups 6ca, 6cb, and 7, a significant widening - at least 2 mm - was measured in both planes for the NWB condition.Conclusion:WBCT scans improve the ability to detect incomplete ligamentous Lisfranc injuries by comparing C1-M2 distance to the uninjured side. Widening exceeding 1 mm more than the normal contralateral side for the PWB condition could clinically indicate complete Lisfranc ligament injury (sensitivity 83.3%, specificity 88.9%, accuracy 87.5%).

Ligamentous Lisfranc injuries: analysis of CT findings under weightbearing.

The aim of this study was to investigate the influence of different ligamentous Lisfranc injuries on computed tomography (CT) findings under weight-bearing and to emphasize the indications for surgical treatment of their various types. Sixteen human cadaveric lower limbs were placed in weight-bearing radiolucent frame for CT scanning. All intact specimens were initially scanned, and then, dorsal approach was used for sequential ligaments cutting of: (1) the dorsal and the interosseous (Lisfranc) ligaments between medical cuneiform (MC) and metatarsal 2 (MT2); (2) the plantar ligament between the MC and MT3; (3) the plantar ligament between MC and MT2. Based on sequential CT scans, the distances MT1-MT2, MC-T2, as well as the alignment and dorsal displacement of MT2 were measured. Slight increase in the distances MT1-MT2 and MC-MT2 was observed after the disruption of the dorsal and the interosseous ligaments. Further increase in MT1-MT2 and MC-MT2 distances was registered after the disruption of the ligament between MC and MT3. The largest distances MT1-MT2 and MC-MT2 were measured after the final plantar ligament cut between MC and MT2. Unequivocal instability is observed with simultaneous transection of the Lisfranc ligament with both plantar ligaments. On CT used as diagnostic tool, plantar injuries at the basis of the second and the third metatarsal are indirect signs of violation of the ligaments and represent an indication for surgical treatment. When using magnetic resonance imaging as diagnostic tool, a ruptured Lisfranc ligament alone without dislocation does not necessarily need surgical intervention.

Biomechanical Evaluation With a Novel Cadaveric Model Using Supination and Pronation Testing of a Lisfranc Ligament Injury.

Background:Lisfranc joint injuries can be due to direct or indirect trauma and while the precise mechanisms are unknown, twisting or axial force through the foot is a suspected contributor. Cadaveric models are a useful way to evaluate injury patterns and models of fixation, but a frequent limitation is the amount of joint displacement after injury. The purpose of this study was to test a cadaveric model that includes axial load, foot plantarflexion and pronation-supination motion, which could re-create bone diastasis similar to what is seen in subtle Lisfranc injuries. Our hypothesis was that applying pronation and supination motion to a cadaveric model would produce reliable and measurable bone displacements.Methods:Twenty-four fresh-frozen lower leg cadaveric specimens were used. The medial (C1) and intermediate (C2) cuneiforms and the first (M1) and second (M2) metatarsal bones were marked. A complete ligament injury was performed between C1-C2 and C1-M2 in 12 specimens (group 1), and between C1-C2, C1-M2, C1-M1, and C2-M2 in 12 matched specimens (group 2). Foot pronation and supination in addition to an axial load of 400 N was applied to the specimens. A 3D digitizer was used to measure bone distances.Results:After ligament injury, distances changed as follows: C1-C2 increased 3 mm (23%) with supination; C1-M2 increased 4 mm (21%) with pronation (no differences between groups). As expected, distances between C1-M1 and C2-M2 only changed in group 2, increasing 3 mm (14%) and 2 mm (16%), respectively (no differences between pronation and supination). M1-M2 and C2-M1 distances did not reach significant difference for any condition.Conclusions:Pronation or supination in addition to axial load produced measurable bone displacements in a cadaveric model of Lisfranc injury using sectioned ligaments. Distances M1-M2 and C2-M1 were not reliable to detect injury in this model.Clinical Relevance:This new cadaveric Lisfranc model included foot pronation-supination in addition to axial load delivering measurable bone diastasis. It was a reliable Lisfranc cadaveric model that could be used to test different Lisfranc reconstructions.

Return to Sport after Surgical Treatment of Lisfranc Injuries in Athletes: A Retrospective Case Series

A Lisfranc injury can be a devastating injury in athletes, and if inadequately treated, may lead to chronic pain and loss of function. The purpose of this study was to determine the rate and time until return to sport after surgical fixation for a ligamentous Lisfranc injury. We hypothesized that open reduction and screw fixation of a ligamentous Lisfranc injury can be a successful treatment in the athletic population and allow patients to return to sport at close to their preinjury level of play. All patients who were analyzed underwent repair of a ligamentous Lisfranc injury with open reduction and screw fixation by a single surgeon, were between 18 - 40 years old at time of their final follow up, and were identified as being an athlete (either recreational or competitive). Eligible patients were given a questionnaire that included if they were able to return to sport, time until return to sport, subjective percentage of pre-injury level of play, current pain (0 - 10), and complications. Eleven patients were identified as athletes. Ten (91%) were available for follow-up with a mean of 36.5 months (range, 14 - 60). The average age was 25.4 years (range, 15 - 37) at time of surgery. Eighty percent (8/10) were able to return to sport. The average time until return to sport was 29.4 weeks (range, 22 - 52) with an average subjective value of their pre-injury level of play of 87% (range, 70 - 100%). However, 67% (6/9) of the athletes had occasional pain with sport with an average pain level of 2.1 (range, 0 - 5). Two patients had complications, a superficial infection and a deep vein thrombosis. Most athletes were able to return to sport after undergoing open reduction and internal fixation of a ligamentous Lisfranc injury by less than 30 weeks post-surgery with a subjective value of 87% of their previous function. However, the majority of the patients also experienced some residual pain with their respective sport. These findings suggested that athletes with a ligamentous Lisfranc injury can have reliably good outcomes with operative repair.

Ultrasound as a Diagnostic Tool in the Assessment of Lisfranc Joint Injuries.

Ligamentous Lisfranc injuries are frequently overlooked because of subtle clinical presentations and diagnostic difficulties. The dorsal Lisfranc ligament (DLL) is easily visualized with ultrasound (US), which can provide quick, cost-effective diagnoses of disorders but is not considered standard clinical practice. This study sought to compare DLL measurement accuracy between US and cadaveric dissection. Ultrasound images of 22 embalmed cadaveric feet were obtained with an M-Turbo US machine and a 6-13-MHz linear array (FUJIFILM SonoSite, Inc, Bothell, WA). Images were measured in the US unit and again with ImageJ software (National Institutes of Health, Bethesda, MD). Specimens were dissected, and DLL morphologic characteristics were recorded. Twenty-two specimens were scanned, however 4 were excluded, leaving a sample of 11 male and 7 female cadaveric specimens (mean age ± SD, 80.3 ± 14.03 years). The DLL length differences between SonoSite (8.39 ± 1.27 mm) and ImageJ (8.25 ± 1.84 mm) were not significant (P > .05). Both US DLL measurements significantly differed from the gross dissection measurement (10.8 ± 1.85 mm; P < .001). The morphologic characteristics of the DLL at dissection were consistent. Overall, 70% to 80% of the ligament length was represented by US compared to dissection. The dorsal joint space did not differ significantly between SonoSite (2.19 ± 0.49 mm) and ImageJ (2.05 ± 0.52; P > .05). Both US measurements were also significantly larger than dissection measurements (1.04 ± 0.24; P < .001). Intraclass correlation coefficients indicated good reliability for the DLL length (0.835) and moderate reliability for the dorsal joint space (0.714). The DLL is underrepresented but easily distinguished by US, demonstrating its utility in Lisfranc injury diagnosis. Thus, we propose a 4-component assessment involving US, which may provide more rapid, cost-effective diagnoses of subtle Lisfranc injuries.

InternalBrace Has Biomechanical Properties Comparable to Suture Button but Less Rigid than Screw in Ligamentous Lisfranc Model

Category:Midfoot/Forefoot, TraumaIntroduction/Purpose:Lisfranc injuries occurring between the medial cuneiform and base of the 2nd metatarsal require anatomic fixation. Suture button and screws are standard techniques for fixation, but the screw may decrease physiologic motion, whereas suture buttons may cause increased soft tissue irritation and iatrogenic cartilage damage. Potential benefits of the InternalBrace include physiologic motion, decreased iatrogenic damage, collagen ingrowth, limited bony erosion and decreased soft tissue irritation. In light of these potential benefits, no studies have investigated the biomechanical properties of the InternalBrace in a Lisfranc injury model. However, it is unknown whether there is significant difference in the biomechanical properties of the IB compared to the screw, or SB during load to failure, and cyclical loading.Methods:Three groups of sawbones were fixed together with either a 3.5 mm screw, SB, or IB, composed of a curved button, fibertape, and 4.75 mm biotenodesis screw. Sawbone constructs were held in a mechanical testing system (Model 809, MTS Systems Corp, Minneapolis MN). The first three groups of 10 were loaded in axial tension at 0.5mm/sec until failure to determine load-displacement data. Yield, stiffness, ultimate strength (US), yield energy, post-yield energy and ultimate strength energy were calculated. Three more groups of 8 constructs were loaded in-vitro at cyclical physiologic loads until displacement of 1.5 mm occurred. Constructs were first loaded for 10,000 cycles at 69 N (estimate for 50% body weight or assisted walking). Surviving specimens were loaded at 138 N (normal walk) for an additional 10,000 cycles and then 207 N (jog) for an additional 10,000 cycles. Displacement was recorded. The biomechanical properties were then compared between groups.Results:When loaded in axial tension at 0.5mm/sec until failure, the screw was found to be the stiffest construct (2,240 N/mm), while the InternalBrace (200 N/mm) was stiffer than the suture button (133 N/mm). Qualitatively, the InternalBrace was also found to hold load more consistently and for larger displacement prior to failure when compared to the suture button. Cyclic loading was performed with 10,000 cycles of 69 N, 138 N, and 207 N. The screw had the greatest resistance to fatigue. The InternalBrace maintained stiffness as well or better than the suture button, but the fatigue life was shorter than that of the suture button.Conclusion:To our knowledge, the biomechanical properties of the IB have not been compared to screw and SB for ligamentous lisfranc injuries. This study gives valuable information about the mechanical integrity of InternalBrace and supports continued use. However, further studies are warranted before making conclusions regarding early weight bearing.

Flexible Fixation Technique for Lisfranc Injuries.

Injuries to the Lisfranc complex range from purely ligamentous disruptions to fracture-dislocations of the tarsometatarsal joint. Treatment options include closed/open reduction with percutaneous pinning, open reduction and internal fixation (ORIF), and primary arthrodesis. We present a ligament reinforcement technique utilizing a flexible fixation device for the treatment of ligamentous Lisfranc injuries. Level of Evidence: Level V, expert opinion.

Lisfranc open reduction and internal fixation in an athletic population: screw versus suture button fixation

Background: Primarily ligamentous Lisfranc injuries occur in athletic populations. Unstable Lisfranc injuries are treated with internal fixation or arthrodesis. Internal fixation has been described with both screws and suture button devices, but there currently are only case reports in the medical literature describing the use of suture buttons. This study assessed the return to duty rate, time to full activity, hardware removal rate, and complications after open reduction and internal fixation (ORIF) of primarily ligamentous Lisfranc injuries in an active duty military population, comparing screw fixation with suture button fixation. Methods: A retrospective review was performed of ORIF of Lisfranc injuries performed at our institution from 2009-2012. Inclusion criteria were active duty at the time of surgery, primarily ligamentous Lisfranc injuries undergoing ORIF, and minimum 6-month follow-up. Twelve patients were identified who met the inclusion criteria. Results: Six patients underwent screw fixation (five men and one woman with a mean age of 25.7 yr). Six underwent suture button fixation (five men and one woman, with a mean age of 29.7 yr). Only half of the patients in the screw fixation group returned to full activity, whereas all patients in the suture button fixation group returned to full activity. Average time to return to full activity was 358 days in the screw fixation group and 181 days in the suture button group. The hardware removal rate was 83% in the screw fixation group, with no hardware removals in the suture button group. Conclusions: Our results demonstrate that suture button fixation serves as a viable alternative to screw fixation in an athletic population.

Ligamentous Lisfranc Injury: A Biomechanical Comparison of Dorsal Plate Fixation and Transarticular Screws

Optimal fixation technique after purely ligamentous Lisfranc injury remains controversial. This biomechanical study compares dorsal plate versus transarticular screw fixation by measuring dorsal and plantar joint diastasis. A unique protocol was developed, using reflective triad markers and positional cameras. Eleven cadaveric matched pairs were assigned to either transarticular screw or dorsal plate fixation. Two reflective triad markers were placed into the medial cuneiform (C1) and second metatarsal base (MT2). Three cameras recorded the 3-dimensional location of triads to quantify C1-MT2 diastasis in the following states: intact Lisfranc ligament (INTACT), cut ligament (CUT), fixed (SCREW or PLATE) joint, and fixed joint after 10,000 loaded cycles. On completion, the plantar Lisfranc ligament insertions were identified, and plantar diastasis was determined using additional reflective triads. Statistical post hoc pairwise comparisons assessed differences in diastasis. C1-MT2 diastasis in the CUT state increased relative to INTACT (P < 0.001). SCREW fixation reduced C1-MT2 diastasis relative to CUT at dorsal (P < 0.007) and plantar (P = 0.015) locations after cycling. PLATE fixation significantly reduced dorsal diastasis relative to CUT (P < 0.001) but not for plantar diastasis (P > 0.99). PLATE plantar diastasis was numerically higher than INTACT but not significantly (P > 0.39). PLATE plantar diastasis tended to be greater than SCREW before cycling (P = 0.068) and after cycling (P = 0.080). Transection of the Lisfranc ligament complex yielded C1-MT2 diastasis. Both SCREW and PLATE fixation successfully reduced dorsal diastasis. However, upon load, the PLATE resulted in greater plantar diastasis, nearly statistically different relative to the SCREW. Cyclic loading at 343 N did not worsen diastasis.

New Flexible Fixation for Subtle Lisfranc Injury

Lisfranc ligament injuries are not so common and often overlooked. If missed, they can cause long-term disability and pain. The treatment of these injuries are still controversial and very little is known about which types of injury can be treated without surgery. Successful surgical management of these injuries is predicated on anatomic reduction and stable fixation. Open reduction and internal fixation remains the standard treatment, although ligament reconstruction has emerged as a viable option for certain types of tarsometatarsal joint injuries. This paper describes the authors’ approach to treat Lisfranc’s pure ligament injury. It presents a particular view of the problems resulting from the diagnosis and a specific type of ligament reconstruction. Level of Evidence: Level V.

Undisplaced subtle ligamentous Lisfranc injuries, conservative or surgical treatment with percutaneous position screws?

PurposeUndisplaced subtle ligamentous Lisfranc injuries are easy to miss or underestimate, and many cases are treated without surgical fixation. It has not yet widely known whether conservative treatment for undisplaced subtle ligamentous Lisfranc injuries may lead to a poor outcome. The purpose of this study is to compare the outcomes of conservative versus surgical management (percutaneous position screw) of undisplaced subtle ligamentous Lisfranc injury. MethodsWe analysed 61 cases in this retrospective study, including 38 males and 23 females. Forty-one patients were managed conservatively, while 20 patients received surgical treatment involving minimal invasive percutaneous position screw. American orthopaedic foot &ankle society (AOFAS), foot function index (FFI, including FFI disability, FFI pain score and activity limitation scale) scores, Maryland foot score and short form-36 (SF-36) were recorded and compared after a follow-up of 10–16 months (average 12.3). ResultsPatients in the surgical management group had higher scores in all evaluation methods (p < 0.05). The complications in the conservative management group had higher incidence, mainly including secondary diastasis (34.1% vs. 5.0%), joint stiffness after 3 months (82.9% vs. 0%), and secondary arthrodesis (12.2% vs. 0%). The highest rate of complication in surgical management group was temporary forefoot pain (55.0%). ConclusionThe results of this study suggest that the outcomes of the surgical management with percutaneous position screw fixation are better than the conservative management to treat undisplaced subtle ligamentous Lisfranc injuries. This study can serve as a resource for orthopaedic surgeons in recognizing and managing such injuries.

Flexible Fixation Treatment Strategies for Low-energy Lisfranc Injuries

Ligamentous Lisfranc injuries are characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal. Ligamentous injuries can be either subtle or obvious and can also occur with tarsometatarsal subluxations or dislocations. These injuries typically happen in athletic activity and are also seen lower-energy falls. Conventional use of transarticular screws to repair Lisfranc ligament injuries has provided good outcomes; however, the screws are also believed to decrease the natural physiological movement of the Lisfranc joint. As treatment options for ligamentous Lisfranc injuries move away from transarticular screws and toward bridge plating and motion-preserving fixation techniques, the goal of stable fixation is still important for optimizing long-term results. This article will focus on the technique of using a suture button device, and also introduce the technique of Lisfranc InternalBrace fixation. The internal brace technique allows for less bone loss from drilling, allows for collagen ingrowth, and can be used in conjunction with bridge plating techniques. Level of Evidence: Diagnostic Level 4. See Instructions for Authors for a complete description of levels of evidence.

Appropriate MRI Evaluation of Lisfranc Ligaments: How to Avoid Missing Ligamentous Lisfranc Injuries

Knowledge of injuries at the tarsal metatarsal joints continues to evolve. Fractures and ligamentous injuries at the tarsal metatarsal joints, also known as the Lisfranc joint complex, are uncommon yet can be of great clinical significance. The initial radiographic findings, suspected mechanism of injury, and physical examination findings can result in varying diagnoses and recommendations. Subtle or ligamentous injuries can be missed and result in the potential of midfoot instability and rapid progression to posttraumatic osteoarthritis. The imaging features of injury at the Lisfranc joint are reviewed, and guidance is provided as to the appropriate use and interpretation of weight bearing radiographs, computed tomography, and magnetic resonance imaging. This will include a description on the utilization of magnetic resonance imaging in evaluating ligamentous Lisfranc injuries to aid clinicians in successfully diagnosing a ligamentous or subtle injury.

Open Reduction and Internal Fixation of Acute Lisfranc Fracture-Dislocation with Use of Dorsal Bridging Plates.

Lisfranc injuries consist of a wide spectrum of injuries, ranging from subtle injuries to severe fracture-dislocations. Injuries with instability of the tarsometatarsal, intercuneiform, or naviculocuneiform joints should be treated with anatomic reduction and stable fixation. The best method of fixation is debated. Transarticular screw fixation has the disadvantage of damaging the tarsometatarsal joints. Bridging the tarsometatarsal joints with use of low-profile locking plates avoids the placement of screws through the joint and potentially reduces the risk of posttraumatic arthritis. Primary arthrodesis of the 3 medial tarsometatarsal joints is also an option in treating Lisfranc injuries and has been shown to lead to better outcomes compared with transarticular screw fixation in ligamentous Lisfranc injuries. In this article, we show the technique of open reduction and internal fixation of Lisfranc fracture-dislocation with use of dorsal bridging locking plates. The following steps are presented in the video: (1) incision technique with use of a dorsomedial incision and a dorsolateral incision, (2) open reduction and temporary fixation of the tarsometatarsal joints with use of Kirschner wires, (3) confirmation of anatomic reduction of the tarsometatarsal joints with direct visualization and fluoroscopy, (4) fixation of the medial 3 tarsometatarsal joints with dorsal bridging locking plates, (5) placement of a "homerun" screw from the medial cuneiform to the base of the second metatarsal, (6) fixation of the fourth and fifth tarsometatarsal joints with Kirschner wires, and (7) checking of reduction and fixation with use of fluoroscopy and performance of wound closure. Postoperatively, the foot is kept non-weight-bearing in a below-the-knee cast for 6 weeks, followed by 6 weeks of protected weight-bearing in a walker boot. Any Kirschner wires fixating the fourth and fifth tarsometatarsal joints are removed 6 weeks postoperatively. We prefer to remove the dorsal bridging plates 4 to 6 months postoperatively. Anatomic reduction and stable fixation is associated with better functional outcomes. Hardware failure and loss of reduction are potential complications that can lead to worse outcomes.

Magnetic resonance imaging of the Lisfranc ligament

BackgroundThe Lisfranc joint has complex structures, and articular surfaces overlap on conventional X-ray radiographs. Hence, there is no available auxiliary examination for diagnosing related injuries. At present, few studies on the imaging of Lisfranc ligaments have been reported, and related imaging data are rare. Therefore, no imaging reference can be used for related diagnosis and repair operations. This study aims to observe and describe the morphology and structure of Lisfranc ligaments using magnetic resonance imaging (MRI), in order to provide imaging reference for the diagnosis and repair of Lisfranc joint injuries.MethodsMRI scanning was performed on 60 sides of normal feet of 30 healthy adult volunteers. In the MRI scanning on the Lisfranc joint, sagittal scanning was focused on the area between the lateral margin and medial margin of the Lisfranc joint, while oblique coronal scanning was focused on the area parallel to the Lisfranc joint clearance. After acquisition of MRI images, data were burned into a CD, and the morphology and structure of the Lisfranc ligament on the MRI image were observed and described. Hence, the imaging parameters of the Lisfranc ligament were acquired, providing an imaging reference for the diagnosis and repair of Lisfranc joint injuries.ResultsBy observing the obtained images of the Lisfranc ligament through appropriate MRI scanning, it was found that the Lisfranc ligament originates at the site 12.63 ± 1.20 mm from the lateral side of the base of the medial cuneiform bone, with a length of 8.02 ± 1.5 mm, a width of 2.53 ± 0.61 mm, a height of 6.96 ± 1.01 mm, forms an included angle of 46.79 ± 3.47° with the long axis of the first metatarsal bone, and finally ends at the base of the second phalanx. Detailed imaging parameters of the Lisfranc joint and ligament were obtained from the present imaging experiment, providing an imaging reference for the diagnosis and repair of Lisfranc joint injuries.ConclusionsOn the MRI images, the sagittal section can clearly display the corresponding situation of the Lisfranc joint bone and longitudinal arch of the foot, tolerably display the Lisfranc joint dorsal ligaments and metatarsal ligaments, and poorly display the Lisfranc ligament. The oblique coronal section can clearly display the transverse arch of the foot and clearly display the cross-section of the Lisfranc ligament. The oblique crosssection can clearly display the horizontal arch of the Lisfranc joint and more clearly display its surrounding ligaments and tendons, especially the entire Lisfranc ligament and its attachment points. This is an important section for the diagnosis of Lisfranc ligament injuries. This study provides a certain imaging reference for the MRI scanning, diagnosis, and repair of Lisfranc joint injuries. Further research with large sample size is still needed to confirm the conclusions.

Injury Pattern in Ligamentous Lisfranc Injuries in Competitive Athletes.

We report data on the largest cohort to date of patients who sustained a ligamentous Lisfranc injury during sport. To date, the prevalence of concurrent intercuneiform ligament injuries in the competitive athlete with subtle Lisfranc instability has not been reported. Eighty-two patients (64 males, 18 females) sustained an unstable Lisfranc injury (49 left, 33 right) and met inclusion criteria. Injuries were classified as traditional dislocation (TRAD, first to second TMT ligament tear), medial column dislocation (MCD, second TMT, and medial-middle cuneiform ligament tear), or proximal extension dislocation (PE, first, second, and medial-middle cuneiform ligament tear) and the injury pattern confirmed at surgery. All athletes underwent open reduction with internal fixation (ORIF) of each unstable midfoot segment. Fisher exact tests and 2-tailed t tests were used to analyze statistical significance according to injury pattern, sport, gender difference, hindfoot angle alignment, and injured side ( P < .05). Average age of athletes was 21.0 ± 5.3 years old (range 12-40), and return to sports was 7.5 ± 2.1 months. Injury distribution was as follows: TRAD (n = 40), MCD (n = 17), and PE (n = 23). MCD trended toward a longer return to sport (8.4 ± 3.3 months, P = .074). Football was the most common sport at time of injury (n = 48). Wakeboard athletes (n = 5) were older (31.4 ± 3.2, P = .0002), and MCD tears were more prevalent among them ( P = .061). Basketball (n = 13) players were significantly younger (19.1 ± 2.5 years, P = .028) and returned to sports quicker (5.2 ± 0.7, P = .0002). Return to sport data indicated a typical population for athletes with Lisfranc injury in these sports. Proximal extension disruption (intercuneiform ligament tear) occurred in 50% of these low-energy Lisfranc athletic injuries. MCD and PE may be more prevalent than previously understood. This is the first study to document the extent, pattern, and prevalence of associated intercuneiform ligament tears in the competitive athlete with a low-energy subtle, unstable Lisfranc injury. Level IV, retrospective case series.