Lisfranc Ligament Research Articles

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.

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.

LATERAL COLUMN MIDFOOT INJURY: DO THEY ALL NEED FIXATION?

BackgroundResearch on midfoot injuries have primarily concentrated on the central column and the Lisfranc ligament without amassing evidence on lateral column injuries. Lateral column injuries have historically been treated with Kirschner wire fixation when encountered.ObjectiveOur aim in this study was to analyse lateral column injuries to the midfoot, their method of treatment and the radiological lateral column outcomes. Our nul hypothesis being that fixation is required to obtain and maintain lateral column alignment.MethodsData was retrospectively collected from four centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. All statistics was performed using SPSS 26.ResultsA total of 235 cases were diagnosed as having a lateral column injury out of the 409 cases included. On cross tabulation, there was a significant association with having a central column injury (234/235, p&lt;.001) and 70% of cases (166/235) also had an additional medial column injury. Of the 235 lateral column injuries, data was available regarding fixation radiographic alignment on 222 cases. There were 44 cases which underwent Kirschner wire fixation, 23 plate fixations and 3 screw fixations. Lateral column alignment loss was seen in 2.84% (4/141) of those which didn't undergo fixation, 13.64% (6/44) which underwent K wires, and 0 % in those fixed by screws or K wires.ConclusionLateral column injury occurs in over half of midfoot fractures in this study. It rarely occurs alone and is most commonly related to three column injuries. Nevertheless, following stabilisation of the central column, additional fixation of injuries to the lateral column do not appear beneficial. The use of a bridge plate to fix the central column appears protective and purely ligamentous injury was a higher risk than an injury that included the bone.

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.

Antibiotic-loaded cement: A viable alternative to amputation in the treatment of diabetic foot osteomyelitis - A case report

This article shows the long-term success of surgical debridement and antibiotic-loaded cement spacers, as an alternative to amputation, in a 32-year-old male diabetic Type I patient with Osteomyelitis (OM) of first metatarsal base and medial cuneiform of the left foot. OM is a common complication of diabetic foot infections and when it involves the proximal phalanx or metatarsal head, amputation at the Lisfranc ligament level is the recommended treatment. However, its management is not well standardized yet. The objective of this article is to describe the treatment with bone curettage and filling with antibiotic-loaded cement and its mid-term clinical outcomes, as an alternative to usual management. Local antibiotic treatment with cement could be equally effective as amputation without the morbid and functional implications that the latter option entails, nevertheless more evidence is required to develop general recommendations.

Charcot neuroarthropathy in persons with diabetes: It's time for a paradigm shift in our thinking.

The aim of this paper is to review the recent literature regarding the epidemiology and surgical management of Charcot neuro-osteoarthropathy (CNO). We propose that a fundamental change in the approach and assumptions regarding the historical treatment of active CNO should be considered. Although the true incidence and prevalence of CNO in the US population with diabetes are not known, we estimated the incidence to be 27,602 per year and the prevalence to be 208,880 persons. In persons with diabetes, the incidence of CNO is higher than that of prostate, lung, kidney, and thyroid cancer, and in the entire US population, the incidence of CNO is higher than that of multiple myeloma, soft tissue sarcoma, and primary bone sarcoma. In persons with diabetes, the incidence of CNO is higher than fractures of the femoral shaft, distal femur, tibia, talus, calcaneus and Lisfranc ligament injuries. Surgical techniques have evolved over the past half century, and surgery is the standard for treating displaced fractures and intra-articular injuries. Since CNO is a fracture, dislocation, or fracture dislocation in patients with neuropathy, why do we treat CNO differently? Elsewhere in the skeleton displaced osseous and ligament injuries are treated surgically. Based on the information presented in this manuscript, we suggest that it is time for a paradigm shift in the treatment of persons with CNO. While uncommon, CNO in persons with diabetes is not rare. Given the advances in surgical techniques, surgical intervention should be considered earlier in persons with CNO who are at risk for developing deformity related foot ulceration.

Intercuneiform Instability is Present in Midfoot Arthritis Patients: A 3D Volumetric Case-Control Assessment

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Lisfranc complex stability, primarily coming from the tarsometatarsal ligaments, is crucial for midfoot integrity. It has been shown that Lisfranc injuries can lead to midfoot issues, such as midfoot arthritis when not properly diagnosed/treated. Previous studies have estimated the volumes of the articulating joint volumes of surgically confirmed Lisfranc Ligament injuries, but no study has assessed articulating joints and space-of-interest of the Lisfranc Complex in patients with midfoot arthritis. The objective of this retrospective study was to determine if patients with confirmed midfoot arthritis have increased volumes at the Lisfranc complex when compared to controls, particularly between the first and second rays. We hypothesized that volumes would be increased in midfoot arthritis patients, consistent with medial column/first ray instability. Methods: In this IRB-approved, retrospective case-control study, we analyzed WBCT data of 20 consecutive midfoot arthritis patients and 20 healthy controls. Using an automated segmentation method (DISIOR Bonelogic 2.0, Paragon28, USA), 3D volumetric models of the bones of the foot were created from WBCT data. Opposing articular spaces in the Lisfranc joint of the midfoot were selected on the STL models of the bones. Interarticular distance mapping was then performed to characterize the joint space width (JSW) in each of the articulations. Interarticular volume was then estimated using an area-weighted volume measurement. Areas of each triangle from the triangulated surface were multiplied by the JSW at each triangle. The sum of individual volumes was then normalized by the total surface area. The final volume was estimated using the product of the normalized summation and average area of both surfaces. Comparisons were performed with independent t-tests. P-values &gt;0.05 were considered significant. Results: Estimates of joint volume were obtained using the automated method written in MATLAB. These outputs are reported in Table 1. Significant increase of approximately 25% was observed in Midfoot arthritis patients at the 1-2 intercuneiform joint, consistent with intercuneiform instability. Conversely, a decrease in the space between the second metatarsal and medial cuneiform of about 30% was observed, what could be explained by pronation of the first ray secondary to first ray instability. All other changes in joint volumes were not significant (Figure). Conclusion: In this case-control study with midfoot arthritis patients and healthy controls we performed a 3D volumetric assessment of the Lisfranc Complex joints and spaces-of-interest. We found that midfoot arthritis patients have a significant increase in the 1-2 intercuneiform joint consistent with intercuneiform instability. Conversely, a decrease in the Lisfranc space (in between second metatarsal and medial cuneiform) was observed, what could be explained by first ray pronation in the setting of medial column instability. Additional prospective studies assessing angular measurements and patient reported outcomes are needed.

Comparison of flexible fixation and screw fixation for isolated Lisfranc ligament injuries: A protocol for a meta-analysis of comparative studies.

Background:The frequency of isolated Lisfranc ligament (ILL) injuries has been increasing recently with the increase in low-energy trauma resulting from sports injuries. For ILL injuries, the optimal method of fixation still remains controversial. The traditional fixation method is achieved by trans-articular screws, but recently, dorsal bridge plates and suture button (SB) fixation have become alternatives. Some biomechanical studies have showed that SB fixation can provide adequate strength compared to trans-articular screws. Therefore, a meta-analysis is imperative to provide evidence on whether flexible fixation is comparable to screw fixation for treatment of ILL injuries.Methods:We will conduct a comprehensive literature search in PubMed, Cochrane Library, EMBASE and Web of Science databases and for comparative studies. We will apply the risk-of-bias tool of the Cochrane Collaboration for Randomized Controlled Trials to assess the methodological quality. Risk-of-Bias Assessment Tool for Non-randomized Studies was used to evaluate the quality of comparative studies. Statistical analysis will be conducted using RevMan 5.4 software (Cochrane Collaboration, London, England).Results:This systematic review will evaluate the functional outcomes and radiographic results of flexible fixation for treatment of ILL injuries.Conclusion:The conclusion of this study will provide evidence for judging whether flexible fixation is superior to screw fixation for treatment of ILL injuries.

Reliability of Weight-Bearing Ultrasonography for Diagnosis of Lisfranc Joint Injuries: A Cadaveric Study

Category: Trauma Introduction/Purpose: Ultrasonography is increasingly used to evaluate the stability of various joint in the field of foot and ankle. This study aims to assess and compare the Lisfranc joint stability under stimulated weight bearing condition among progressive stages of Lisfranc ligamentous complex injuries. All the measurements were assessed using ultrasonography, fluoroscopy, and direct open measurement. We hypothesize that there is a correlation between ultrasonographic and fluoroscopic measurements, or between ultrasonographic and direct open measurements when performing stress evaluation of the Lisfranc instability. Methods: Twelve fresh below-knee amputated cadaveric specimens underwent ultrasound, fluoroscopic, and direct gross evaluation of the Lisfranc stability under simulated weight bearing condition. The assessment was first performed with all Lisfranc ligamentous complex intact and thereafter with sequential transection of the dorsal Lisfranc ligament, interosseous Lisfranc ligament, and plantar Lisfranc ligament. The simulated weight bearing condition was performed with 600N of force. The distances evaluated during the experimental set up were C1-M1, C2-M2, C1-M2, C1-C2 and M1-M2. All measurements were recorded in millimeter (mm). The ultrasound machine (GE, LOGIQ E-9 ultrasound machine, Chicago, Illinois, USA) was used to assess the Lisfranc stability by measuring the distances between the hyperechoic bone contours or the pre-defined landmark of the metatarsal and cuneiform bones. Correlations between 1) Ultrasound and fluoroscopic measurements, 2) Ultrasound and direct open measurements, and 3) Fluoroscopic and direct open measurements were evaluated using Pearson correlations coefficient. Results: Strong positive correlations between ultrasonographic and direct open measurements were found when assessed for C1-M1, C1-M2, C1-C2, M1-M2 (Pearson's correlation ranged from 0.73-0.97, p-values &lt;0.001). Strong positive correlations between ultrasonographic and fluoroscopic measurements were found when assessed for C1-M1 from dorsal, medial, and plantar aspect (Pearson's correlation ranged from 0.75-0.90, p-values &lt;0.001). Strong positive correlations between fluoroscopic and direct open measurements were found when assessed for C1-M1, C1-M2, C2-M2, M1-M2 (Pearson's correlation ranged from 0.77-0.93, p-values &lt;0.001). Inter-rater and intra-rater reliability for the ultrasonographic measurements between the MSK radiologist (TK) and the foot and ankle surgeon (JS) were substantial (ICC ranged from 0.81-0.98). Conclusion: Ultrasonography is a reliable and reproducible tool for diagnosing Lisfranc ligamentous complex injuries. Both ultrasonographic and fluoroscopic measurements appear to strongly correlate with values measured by direct open measurement. Based on these data, ultrasonography is likely to become a valuable point of care diagnostic tool due to its ability to readily and dynamically evaluate suspected Lisfranc ligamentous complex injuries, without radiation exposure.

Lateral Column Midfoot Injury: Do They All Need Fixation?

Category: Trauma; Midfoot/Forefoot Introduction/Purpose: Research on midfoot injuries have primarily concentrated on the central column and the Lisfranc ligament without amassing evidence on lateral column injuries. Lateral column injuries have historically been treated with Kirschner wire fixation when encountered. Our aim in this study was to analyse lateral column injuries to the midfoot and their treatment. Methods: Setting: Multicentre observational study Methods: Data was retrospectively collected from three centres on surgically treated midfoot fracture dislocations between 2011 and 2021. Radiographs were analysed using departmental PACS. All statistics was performed using SPSS 26. Results: A total of 113 cases were diagnosed as having a lateral column injury out of the 242 cases included. On cross tabulation, there was a significant association with having a central column injury (112/113, p&lt;.001) and 70% of cases also had an additional medial column injury. Of the 113 lateral column injuries which underwent fixation of the central column, only 13 had undergone Kirschner wire fixation of the lateral column. There were no reported loss of lateral column alignment in either the temporary fixation or no fixation groups in this study. Conclusion: Lateral column injury occurs in almost half of midfoot fractures in this study. It rarely occurs alone and is most commonly related to three column injuries. Nevertheless, following stabilisation of the central column, injuries to the lateral column are unlikely to require any further stabilisation with no reported loss of alignment in our study without lateral column fixation.

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 &gt;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.

Lisfranc Injury - Gymnastics

HISTORY: The patient was a 17-year-old ASG level 10 female gymnast who was performing a power tumbling pass on the floor exercise when she felt a crack in her left foot upon landing. She was unable to weight-bear and had to withdraw from the competition. PHYSICAL EXAMINATION: The patient presented to our office the two days later with mild swelling of the foot, but she could not bear weight without pain. She had no foot deformities with a normal arch. The patient was neurologically intact to light touch and motor strength in both lower extremities. She had a positive squeeze test. She was maximally tender to palpation at the first and second TMT joints. Rotation of the midfoot caused her the most pain, but her tibiotalar and subtalar joints were pain free and mobile without pain. DIFFERENTIAL DIAGNOSIS: 1. Left foot ligament sprain 2. Left midfoot fracture 3. Bone contusion TEST AND RESULTS: XR non-weight-bearing AP and lateral: no definite abnormal finding XR weight-bearing AP and lateral: no definite abnormal finding MRI w/o IV contrast: Lisfranc ligament: surrounding edema with partial tears, suspicion for fracture - midfoot CT w/o IV contrast: minimally displaced avulsion fracture of the plantar base of the second metatarsal FINAL/WORKING DIAGNOSIS: Midfoot Lisfranc joint ligament tears with avulsion fracture at the second metatarsal TREATMENT AND OUTCOMES: 1. Non-weightbearing boot for 4 weeks with crutches 2. Partial weightbearing boot for 4 weeks followed with organized PT for 3 months 3. Due to COVID, physical therapy performed mostly at home 4. Resumed gymnastics 32 weeks post-injury full time with no sequelae; accepted scholarship from the Ohio State University gymnastics team

Morphology of the Lisfranc Joint Complex

Lisfranc injuries are complicated injuries of the tarsometatarsal joint with high rates of sequelae. Both anatomy and injury of the Lisfranc joint are variably documented. Descriptions of these injuries and their associated structures vary greatly. The most injured structures are those of the Lisfranc joint complex, which involves the medial cuneiform, second and third metatarsals, and the dorsal, interosseous, and plantar Lisfranc ligaments. This study sought to examine morphology of the Lisfranc joint in cadavers. Twenty-two embalmed cadaveric feet were dissected (13 male, 9 female, 80.3 years ± 14.03) to isolate the bones and ligaments of the Lisfranc joint complex. The dorsal, interosseous, and plantar Lisfranc ligaments were present in each specimen. Each ligament was measured and morphology noted. The dissected dorsal Lisfranc ligament had consistent morphology (mean=10.8 mm ± 1.79). The interosseous Lisfranc ligament had a consistent path, but 11/17 of specimens possessed a connection to the plantar Lisfranc ligament. The plantar Lisfranc ligament demonstrated wide variability with a Y-variant (n=3) and a fan-shaped variant (n=14). Ligament thickness was greatest in the interosseous Lisfranc ligament (mean=13.74 ± 3.08) and least in the dorsal Lisfranc ligament (mean=1.36 ± 0.42). While the objective of defining joint and ligament morphology was achieved, further questions were raised. Variations of the interosseous and plantar Lisfranc ligament may play a role in susceptibility to joint injury, and arthritic changes to the joints examined raise questions regarding the prevalence of arthritis in the uninjured Lisfranc joint.

Shortening the Return-to-Play Times in Elite Athletes With Unstable Isolated Lisfranc Ligament Injuries Using a Knotless Interosseous Suture Button: Case Series and Literature Review.

Background:Isolated unstable Lisfranc ligament injuries in elite athletes are associated with a lengthy period of rehabilitation and prolonged absence from competition.Purpose:To assess the efficacy of a knotless, interosseous suture button system for repairing isolated unstable ligamentous Lisfranc injuries and its capacity to allow accelerated rehabilitation with earlier weightbearing and return-to-play times in elite athletes.Study Design:Case series; Level of evidence, 4.Methods:The authors retrospectively reviewed data from a prospectively compiled database for elite athletes treated by a single surgeon. All included patients had clinical and magnetic resonance imaging evidence of an unstable isolated complete ligamentous Lisfranc injury requiring surgical reduction and stabilization. All patients underwent surgery using a knotless interosseous suture button to achieve stabilization, followed by a standardized postoperative regimen involving full weightbearing at 4 weeks, and all had a minimum postoperative follow-up of 2 years.Results:Included were 12 patients: 7 National Rugby League (NRL) players, 2 professional dancers, 1 Olympic gymnast, 1 professional wakeboarder, and 1 professional NRL referee. The mean age of the patients was 21.1 years (range, 16-34 years). Ten patients underwent acute surgical stabilization within 3 weeks of the injury, and 2 patients sustained chronic isolated Lisfranc instability that was initially treated nonoperatively. All athletes were able to return to full weightbearing by 4 weeks postoperatively, successfully returned to training by 9 to 12 weeks, and returned to full competition by 12 to 16 weeks. No major complications were reported.Conclusion:Knotless interosseous suture button stabilization was a reliable treatment option for both acute and chronic isolated ligamentous Lisfranc injuries in these elite athletes. This technique does not require hardware removal, allows early weightbearing with accelerated rehabilitation, and may shorten the return-to-play interval.

The subtle Lisfranc injury: A case for bilateral weight-bearing radiographs.

A subtle Lisfranc ligament disruption is a rare but potentially devastating injury to the midfoot. If the injury is recognized and treated early, the patient can avoid future arthritic changes and the need for more extensive surgery. The use of bilateral weight-bearing radiographs can aid in the early detection of this subtle injury. This article describes a patient who presented to an orthopedic office with complaints of right foot pain and an inability to participate in physical activity following an intramural sports injury 3 months earlier, and was eventually diagnosed with Lisfranc injury.

Support system of Lisfranc joint complex: An anatomical investigation with an evolutionary perspective

BackgroundThe anatomical arrangement of the Lisfranc joint between the midfoot and forefoot is complex and not just critical for bipedal gait but also for prevention, management, and rehabilitation of injuries in this region. Material and methodsIn forty adult cadaveric lower limbs, the Lisfranc mortise, the ligaments and supports were observed and noted. ResultsThe structural arrangement that accords stability to the joint has osseous, ligamentous, and tendinous components. A bony mortise, which is deep medially, disrupts the linearity of the joint line. An extensive Lisfranc ligament with confluent interosseous and plantar parts was observed. Tibialis posterior, peroneus Longus and Lisfranc ligament exhibit a unique anatomical arrangement that supports the joint inferiorly. ConclusionThe study documents a unique lattice of tendons and ligament offering dynamic support to the joint. Demands of assumption of erect posture and bipedal walking in humans like adduction of the first ray of the foot, maintenance of longitudinal and transverse arches of the foot and ability stiffen midfoot for efficient forefoot take-off are well reflected in the joint structure and supports.

The Diagnostic Accuracy of MRI to Evaluate Acute Lisfranc Joint Injuries: Comparison With Direct Operative Observations.

Background:Early diagnosis is important in patients with Lisfranc joint injury to avoid subsequent complications. As the ligaments in the Lisfranc joint are relatively small and course obliquely, isotropic 3-dimensional (3D) magnetic resonance imaging (MRI) can be beneficial to evaluate ligament injury. The purpose of this study was to investigate the diagnostic accuracy of MRI, including isotropic 3D MRI for acute injury of the Lisfranc joint, especially of the interosseous C1-M2 ligament (Lisfranc ligament), the dorsal C1-M2 ligament (dorsal ligament), and the interosseous C1-C2 ligament, compared with direct operative observations.Methods:This retrospective review identified 27 patients who had undergone MR examination for acute Lisfranc joint injury followed by surgery. We reviewed the operative reports that described the Lisfranc, dorsal, and interosseous C1-C2 ligaments. All patients underwent an MRI, including a 2D oblique plane image parallel to the Lisfranc ligament and an isotropic 3D MRI. An image analysis of the integrity of the 3 ligaments and other associated injuries was performed. The diagnostic accuracy of MRI was analyzed using operative findings as a reference standard.Results:Lisfranc and dorsal ligament injuries were identified on MRI in all patients. MRI depicted disruption of the interosseous C1-C2 ligament in 12 patients. MRI diagnostic accuracy for detection of Lisfranc, dorsal, and interosseous C1-C2 ligaments was 100% (95% CI 0.82-1.0), 74% (95% CI 0.54-0.89), and 70% (95% CI 0.50-0.86), respectively.Conclusion:MRI with oblique planes parallel to the Lisfranc ligament and isotropic 3D MRI was reliable for detecting Lisfranc ligament injury, whereas MRI findings of the dorsal and interosseous C1-C2 ligaments were less consistent with operative observations.Level of Evidence:Level IV, case series.

Flexible Fixation Technique for Subtle Lisfranc Injuries

Background: Subtle Lisfranc injuries represent a primarily ligamentous Lisfranc complex injury involving the Lisfranc ligament and the medial and middle cuneiform ligaments. Static radiographic displacement or dynamic instability of the medial cuneiform and 2nd metatarsal typically warrants operative intervention to prevent chronic functional pain, allow for timely return-to-sport, and mitigate posttraumatic osteoarthritis. Flexible fixation techniques offer a unique solution to the issues seen with transarticular screws, plates, and arthrodesis for ligamentous Lisfranc injuries. Indications: We present the case of a 16-year-old female basketball player with a subtle Lisfranc injury sustained during practice. X-rays show isolated widening of the 1st and 2nd metatarsal bases and dynamic diastasis between the medial and middle cuneiforms. Magnetic resonance imaging (MRI) confirmed a rupture of the plantar Lisfranc ligament. After extensive discussion regarding treatment options, the patient and her family decided to proceed with surgical intervention using a suture anchor and button technique to restore stability to the Lisfranc ligament and intercuneiform complexes. Technique Description: A standardized dynamic examination under anesthesia identifies the extent of the injury. Exposure of the base of the 2nd metatarsal and medial cuneiform is performed. Reduction clamps are applied to restore the intercuneiform relationship and interval between the medial cuneiform and base of 2nd metatarsal. The suture anchor and button construct is placed using fluoroscopic guidance. A final dynamic examination is performed to confirm stability of the construct. Results: Biomechanical studies have shown that flexible fixation maintains physiologic motion about the Lisfranc articulations and has comparable stability to transarticular screws in cadaveric models of isolated Lisfranc ligament insufficiency. Clinical results are limited but demonstrate excellent postoperative functional outcome scores with very few fixation-related complications at 1 to 3 years. Discussion: Flexible fixation techniques for subtle Lisfranc injuries offer unique benefits to transarticular screws, plates, and arthrodesis. We highlight the appropriate evaluation of patients with a suspected subtle ligamentous Lisfranc injury, the surgical technique using a suture button and anchor construct, and review postoperative management and expected outcomes based on the present literature.

To fuse or not to fuse the Lis Franc Joint? The rationale

Introduction: The term “Lisfranc injury” commonly describes injuries which occur at the bases of the five metatarsals, their articulations with the distal four tarsal bones, and the Lisfranc ligament. The injury is rare and accounts for 0.2% of all fractures with up to 20% of injuries being missed in the acute setting. The treatment of these injuries has been the subject of much debate over the years. Primary arthrodesis has increased as a treatment option for acute injuries in the recent literature. Case Report: A 25-year-old female with Type 1 diabetes mellitus presented with a two-week history of a swollen right foot after falling while descending a flight of stairs. Radiographic imaging revealed a partial incongruity of her right Lis franc joint with a comminuted fracture of the second tarsometatarsal joint. She underwent a primary arthrodesis of the Lis Franc joint with no functional impairment or midfoot deformity progression at one year follow up.Conclusion: This construct has shown to better withstand the abnormal biomechanical forces which are placed on the midfoot during ambulation in patients with peripheral neuropathy such as diabetics. The case presented highlights the benefits of this treatment modality in the young, diabetic patient.