Midfoot Injuries Research Articles

Incidence and Characteristics of Midfoot Injuries.

The epidemiology of midfoot injuries is poorly known. It has been estimated that the incidence of Lisfranc injuries (intra-articular injury in the tarsometatarsal joint) is 1/55 000 person-years and the incidence of Chopart injuries (intra-articular injury in the talonavicular and calcaneocuboidal joint) 4/100 000 person-years. The purpose of our study was to assess the computed tomography (CT) imaging-based incidence (per 100 000 person-years) and trauma mechanisms of midfoot injuries. All CT studies performed due to acute injury of the foot and ankle region between January 1, 2012, and December 31, 2016, at Tampere University Hospital were reviewed. Patients presenting with an injury in the midfoot region in the CT scan were included in this study, and their records were retrospectively evaluated to assess patient characteristics. During the 5-year study period, 953 foot and ankle CT scans were obtained because of an acute injury of the foot and ankle. Altogether, 464 foot injuries were found. Of these, 307 affected the midfoot area: 233 (75.9%) the Lisfranc joint area, 56 (18.2%) the Chopart joint area, and 18 (5.9%) were combined injuries or miscellaneous injuries in the midfoot. The incidence of all midfoot injuries was 12.1/100 000 person-years. The incidence of Lisfranc injuries was 9.2/100 000 person-years. The incidence of Chopart injuries was 2.2/100 000 person-years. The incidence of Lisfranc injuries was higher and the incidence of Chopart injuries lower than previously estimated. More than two-thirds of the midfoot injuries in this study were nondisplaced (<2 mm displacement in fracture or joint) and were caused by low-energy trauma. Level III, epidemiologic study.

Functional outcomes of traumatic midfoot injuries

IntroductionMidfoot injuries are rare injuries, often the result of high-energy trauma and occurring in the context of multiple trauma. This study aimed to evaluate functional outcomes and health-related quality of life after open reduction and internal fixation for midfoot injuries at a level 1 trauma center treating complex foot injuries. MethodsRetrospective single level 1 center study with follow-up by questionnaire. All adult patients who underwent open reduction and internal fixation (ORIF) for Lisfranc and/or Chopart injuries between 2000 and 2016 were included and invited to complete the American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Score, the EuroQOL Visual Analog Scale (EQ-VAS), and the EuroQOL five-dimensional questionnaire (EQ-5D-5L). Chart reviews were performed to collect demographic, injury, and treatment characteristics. ResultsForty patients with 45 midfoot injuries were included. Follow-up was available for 29 patients (31 feet), leading to a response rate of 83%. The majority of patients suffered high-energy trauma and nearly all patients had a concomitant injury. Secondary arthrodesis was performed in 7/45 injuries. Median AOFAS score was 64 (IQR 47–78). Higher injury severity score (ISS) was associated with poorer functionality as measured with the AOFAS Midfoot Score (p = 0.046), concomitant injuries were associated with lower quality of life (p = 0.01). EQ-5D scores were significantly lower when compared to the Dutch reference population (p< 0.001). ConclusionsInjuries of the midfoot have negative effects on mid- to long-term quality of life after trauma, with considerable potential for long-term impaired functionality. When counseling patients with these rare injuries after high-energy trauma mechanisms or in the context of multiple trauma, realistic expectations on postoperative recovery should be given.

Classification and operative management of malunion after midfoot injury

Category: Midfoot/Forefoot Introduction/Purpose: To characterize clinical treatment of the malunion after midfoot injury. Methods: 22 cases of malunion following complex midfoot injury from 2004 to 2012. They were 19 men and 3 women with mean age of 37.8. The foot deformity was categorized into 3 types and 3 subtypes, with type? indicating normal foot arch (type ?a forefoot abduction, ?b forefoot adduction and Ic forefoot normal), type? Cavus deformity (subtype is same as?), and type ? flatfoot deformity (subtype is same as?) . There were 2 cases of type?a, 4 cases of type?c, 9 cases of type?a, 4 cases of type ?a, 3 cases of type ?c in our cohort. According to the malunion typing, osteotomy, joint arthrodesis, or realignment was used to correct deformity. Clinical outcomes were evaluated by AOFAS score and VAS. Results: All the patients were followed up for average 34.7 months.The mean VAS score was 2.0 points (0-6) and mean AOFAS score was 83.9±2.3 points (73-94) at the last follow-up, giving an excellent to good rate of 81.8%. All cases obtained favorable functional outcomes without bone nonunion, except one patient who still suffered from midfoot walking discomfort 3 years after operation. Conclusion: Operative management of malunion following midfoot injury is effective and good results can only be obtained by stabilizing injured joint, realignment and recover foot arch.Our typing of the midfoot malunion is helpful in the operative treatment.

Acute injuries and chronic disorders in competitive surfing: From the survey of professional surfers in Japan

Summary Background There have been very few published reports which concerns sports-related acute injuries and chronic disorders sustained during surfing. Therefore, we have been making survey of professional surfers certified by Japan Pro Surfing Association (JPSA) since 2009. Materials and methods Data were collected through the survey of professional surfers certified by JPSA at the competitions and our outpatient clinic. Results Acute injuries during surfing competitions were rare, and commonly happened at lower extremities. Knee MCL injuries, foot and ankle ligamentous injuries were remarkable for lower extremity. Especially, midfoot injuries would be characteristic of competitive surfing, because those injuries happen in aerial manoeuvres which is too difficult to perform for recreational surfers. Chronic disorders of competitive surfers were seen in lower back, shoulder joint, and neck areas. Most of the disorders were diagnosed as myofascitis caused by overuse of muscles during long-time paddling. Conclusions Our results are substantially different from the results of a survey of recreational surfers, and appear to be reflective of the competitive characteristics of surfing.

The Role of the Midfoot in Drop Landings.

The midfoot is instrumental to foot function; however, quantifying its roles in human movement has been difficult. A forceful dynamic activity like landing may help elucidate the midfoot's contribution to foot energetics and function. The main purpose of this study was to measure midtarsal joint kinematics and kinetics during a barefoot single-leg landing task. A secondary aim of this study was to explore the relationship between static foot posture and dynamic midfoot function. In a cross-sectional study design, 48 females (age = 20.4 ± 1.8 yr, body mass index = 21.6 ± 1.7 kg·m) performed drop landings from a height of 0.4 m onto split force platforms. Subjects hung from wooden rings and landed on their dominant leg. Midtarsal joint kinematic and kinetic data were recorded using a 14-camera optical motion capture system in conjunction with two in-ground force platforms and a custom kinetic three-segment foot model. Foot structure was measuring using the arch height index (AHI) and the static midtarsal joint angle from motion capture. Kinematic data revealed an average sagittal plane midtarsal joint range of motion of 27° through the landing phase. Kinetic data showed that between 7% and 22% of the total lower extremity joint, work during the landing was performed by the midtarsal joint. Both standing AHI and static midtarsal joint angle (static MA) were correlated with sagittal plane midtarsal joint range of motion (standing AHI: r = -0.320, P = 0.026; static MA: r = 0.483, P < 0.001) and with midtarsal joint work (standing AHI: r = 0.332, P = 0.021; static MA: r = -0.323, P = 0.025). The midfoot contributes substantially to landing mechanics during a barefoot single-leg landing task. Static foot posture measures have limited value in predicting midfoot kinematics and kinetics during sportlike landings.

Effectiveness of foot fasciotomies in foot and ankle trauma

BackgroundFoot compartment syndrome (FCS) has been reported to cause neuropathic pain, claw or hammer toes, and motor and sensory disturbances. The optimal treatment of FCS is controversial. The purpose of...

Effects of turf and cleat footwear on plantar load distributions in adolescent American football players during resisted pushing

Metatarsal and midfoot injuries are common in American football. Footwear design may influence injury rates by altering plantar foot loading patterns in these regions. The purpose of this study was to determine the effect of cleat design on in-shoe plantar foot loading during a football-specific, resisted pushing task. Twenty competitive football players (age 14.7 ± 1.8 years, height 1.72 ± 0.10 m, and mass 71.8 ± 26.9 kg) completed three trials of pushing a weighted sled at maximal effort in a standard shoe (CLEAT) and artificial turf-specific shoe (TURF), with flexible in-shoe force measuring insoles. Repeated measures ANOVAs identified mean differences in maximum force and relative load under all regions of the foot. Results showed higher forces in the CLEAT under the medial (p < 0.001) and lateral (p = 0.004) midfoot, central (p = 0.007) and lateral (p < 0.001) forefoot, and lesser toes (p = 0.01), but lower forces in the hallux (p = 0.02) compared to the TURF shoe. Additionally, relative loading was higher in the CLEAT under the medial (p < 0.001) and lateral (p = 0.002) midfoot and lateral (p < 0.001) forefoot, but lower in the medial forefoot (p = 0.006) and hallux (p < 0.001) compared to the TURF shoe. The two shoes elicited distinct plantar loading profiles and may influence shoe selection decisions during injury prevention or rehabilitation practices.

Predictors of amputation in high-energy forefoot and midfoot injuries

IntroductionHigh energy injuries to the midfoot and forefoot are highly morbid injury groups that are relatively unstudied in the literature. Patients sustaining injuries of this region are challenging to counsel at the time of injury because so little is known about the short and long term results of these injuries. The purpose of this study was to investigate injury specific factors that were predictive of amputation in patients sustaining high energy midfoot and forefoot injuries. Patients and methods137 patients with 146 injured feet [minimum of two fractures located in the forefoot and midfoot, excluding phalanges, talus, calcaneus, with a high energy mechanism]. Results121 of 146 feet (83%) were treated operatively; 27 patients sustained 34 total surgical amputation events. 30-day amputation rate was 13.9% and 1-year amputation rate was 18.9%; 27 of 146 feet ultimately sustained amputation with 23 of 27 sustaining a below the knee amputation (BKA) and 17 of 23 (73.9%) received a BKA as their first amputation. Statistically significant predictors of amputation included the number of bones fractured in the foot (p=0.015), open injury to the plantar or dorsal surfaces of the foot, Gustilo grade, vascular injury, and complete loss of sensation to any surface of the foot (all p<0.001). Specific fracture patterns predictive of any amputation were fracture of all five metatarsals (p<0.001) and fracture of the first metatarsal (p=0.003). Presence of a dislocation or fracture of the distal tibia were not predictive of amputation. Midterm patient-reported-outcomes (N=51) demonstrated no difference in physical function for patients with and without amputations. ConclusionsHigh-energy forefoot and midfoot injuries are associated with a high degree of morbidity; 1/5th of patients sustaining these injuries proceeded to amputation within 1year. Injury characteristics can be used to counsel patients regarding severity and amputation risk.

Military personnel sustaining Lisfranc injuries have high rates of disability separation

ObjectivesLisfranc injuries are relatively uncommon midfoot injuries disproportionately affecting young, active males. Previous studies in civilian populations have reported relatively good results with operative treatment. However, treatment results have not...

Diagnostic accuracy of the Ottawa Ankle and Midfoot Rules: a systematic review with meta-analysis

ObjectiveTo review the diagnostic accuracy of the Ottawa Ankle and Midfoot Rules and explore if clinical features and/or methodological quality of the study influence diagnostic accuracy estimates.DesignSystematic review with meta-analysis.Data...

The Epidemiology of Lisfranc Injuries at the NFL Combine

Category: Sports Introduction/Purpose: Lisfranc injuries can have detrimental consequences to an athlete’s career. If left inadequately treated, these injuries can result in persistent pain and lead to advanced osteoarthritis. Understanding the prevalence of these injuries in collegiate athletes and their effect on NFL draft position can help team physicians counsel future players and determine optimal treatment. The purpose of this study was to determine the epidemiology of Lisfranc injuries in players participating in the NFL combine and to determine the positions that are at higher risk for sustaining these injuries. Methods: Data was collected from the NFL combine website on all players who participated in the combine and had sustained a Lisfranc injury before entering the NFL from 2009 to 2015. Medical records, imaging, and treatments were reviewed on players who were identified with these injuries. The epidemiology of Lisfranc injuries was determined by evaluating the number of injuries, surgeries, games missed, position played and draft position of each player. Odds ratios were calculated using logistic regression to assess the risk of sustaining each injury by position. Two-sample, two-tailed T-tests were computed to assess games missed and draft position in players with operative versus non-operative management. Players with a Lisfranc injury as well a second primary midfoot injury (n=3) were excluded from analysis. Results: Thirty-nine(1.7%) players at the NFL combine had an isolated Lisfranc injury during their collegiate football career. Of these players, 27(69.2%) required surgical intervention. The average number of collegiate football games missed for this injury was 3.0±5.0. The average number of games missed for players requiring operative fixation was statistically greater(4.2±5.7) than those in the non-operative group (0.3 ±0.9, p=0.02). The average NFL draft position was 141.7±69.4, and 13(33.3%) went undrafted. There was no statistical difference in the average draft position(p=0.84) and number of undrafted players(p=0.15) between the operative and non-operative groups. No position was found to be at increased risk for Lisfranc injury; however, as a whole, offensive players had a significantly increased risk(Odds ratio=2.7, p = 0.01) of having a Lisfranc injury when compared to all other players. Overall, 24(61.5%) of the players with a Lisfranc injury played on offense. Conclusion: The majority of players who reported a Lisfranc injury required operative intervention, and offensive players were at a higher risk for this injury. Lisfranc requiring operative management did not significantly change a player’s draft position or chance of being drafted.

Categorization and surgical management of posttraumatic midfoot malunion

ObjectiveTo assess a classification system for midfoot injury that was based on the characteristics of the foot malunion and to evaluate the suggested treatment strategies.MethodsThis retrospective review of data from patients with posttraumatic midfoot malunion categorized each foot deformity into one of three types based on the foot arch and then separated these categories into one of three subtypes based on the forefoot deformity. According to the types of malunion, fascio-cutaneous flap, osteotomy, joint arthrodesis or realignment was used to correct the deformity. Patients were assessed before surgery and at 12 and 24 months postoperation.ResultsOf the 24 patients identified, six had Lisfranc joint injuries, nine had Lisfranc joint complex injuries combined with cuboid compression fractures and nine had Lisfranc joint complex injuries combined with navicular fractures. Overall, eight patients presented with poor soft tissue and massive scar at the dorsal foot. Visual analogue scale and American Orthopaedic Foot and Ankle Society midfoot scores significantly improved over the 24-month study period. At the end of the study, 21 of 24 patients (87.5%) rated their functional outcome as excellent or good.ConclusionThe classification of the midfoot malunion evaluated in this study may be helpful in the decision making process for surgical intervention.

The patterns of injury and management of cuboid fractures: a retrospective case series.

Although infrequent, a fracture of the cuboid can lead to significant disruption of the integrity of the midfoot and its function. The purpose of this study was to classify the pattern of fractures of the cuboid, relate them to the mechanism of injury and suggest methods of managing them. We performed a retrospective review of patients with radiologically reported cuboid fractures. Fractures were grouped according to commonly occurring patterns of injury. A total of 192 fractures in 188 patients were included. They were classified into five patterns of injury. Type 1 fractures (93 fractures, 48.4%) are simple avulsion injuries involving the capsule of the calcaneo-cuboid joint. Type 2 fractures (25 fractures, 13%) are isolated extra-articular injuries involving the body of the cuboid. Type 3 injuries (13 factures, 6.8%) are intra-articular fractures solely within the body of the cuboid. Type 4 fractures (35 fractures, 18.2%) are associated with disruption of the midfoot and tarsometatarsal injuries. Type 5 fractures (26 fractures, 13.5%) occur in conjunction with disruption of the mid-tarsal joint and either crushing of the lateral column alone or of both medial and lateral columns. Fractures with significant articular disruption or with loss of length of the lateral column underwent fixation. This involved either internal fixation to restore the anatomy of the cuboid and/or restoration of the length of the columns with bridging constructs using internal or external fixation. A classification system for fractures of the cuboid is proposed in relation to the mechanism of injury. The treatment of these fractures is described. Cite this article: Bone Joint J 2016;98-B:1003-8.

Osseous injuries of the foot: an imaging review. Part 1: the forefoot

Injuries to the foot are a common cause for presentation to the ED, and imaging is often used to aid in the diagnosis. The foot can be divided into three...

Implementation of the Ottawa ankle rules by general practitioners in an emergency department of a Turkish district hospital

The present objective was to assess implementation of the Ottawa ankle rules (OAR) as a method of fracture prediction in the emergency department (ED) of a Turkish state hospital. Patients who presented to the ED of our hospital with acute ankle injury were evaluated. All were examined by a general practitioner, after which a series of ankle and foot x-rays (anteroposterior and lateral) were performed. Radiography was examined by a radiologist and an orthopedic surgeon, both of whom were blinded to OAR results. Radiographic results were compared to results of OAR implementation. Sensitivity and specificity of the OAR in the diagnosis of fracture was calculated. A total of 251 (61.97%) patients were diagnosed as positive (+) for fracture after OAR implementation, 154 (38.02%) as negative (-). Clinically significant fracture was detected in 62 (15.3%) patients. A total of 61 (98.4%) patients with significant fracture were OAR (+); 1 (1.6%) was OAR (-). However, 190 (55.4%) patients without fracture were OAR (+); 153 (44.6%) were OAR (-) (p<0.001). Sensitivity, specificity, and positive and negative predictive values of OAR implementation in the prediction of fracture were 98.39%, 44.61%, 24.30%, and 99.35%, respectively. Area under the curve (AUC) was 0.71. According to these results, it was determined that use of radiography could be reduced by 38.02% if the OAR were implemented. The OAR are a highly sensitive means of screening of patients with acute ankle and mid-foot injuries. Application of the OAR by well-trained general practitioners can lead to significant reduction in the number of x-rays performed, thereby reducing cost of treatment and radiation exposure, in addition to saving time for patients and staff.

Midfoot and Forefoot Injuries.

Sports injuries of the midfoot and forefoot encompass a spectrum of osseous and soft tissue trauma. Magnetic resonance imaging serves as a primary or important supplementary diagnostic modality in evaluation of various injuries, most important of which include Lisfranc complex injury, stress fractures, and injury to the first metatarsophalangeal joint, aka "turf toe." Current technical advances in magnetic resonance and improved knowledge of regional anatomy enable thorough evaluation of the complex anatomic structures of the foot and facilitate accurate diagnosis in the setting of trauma.

Incidence and Severity of Foot and Ankle Injuries in Men's Collegiate American Football.

Background:American football is an extremely physical game with a much higher risk of injury than other sports. While many studies have reported the rate of injury for particular body regions or for individual injuries, very little information exists that compares the incidence or severity of particular injuries within a body region. Such information is critical for prioritizing preventative interventions.Purpose:To retrospectively analyze epidemiological data to identify the most common and most severe foot and ankle injuries in collegiate men’s football.Study Design:Descriptive epidemiology study.Methods:Injury data were obtained from the National Collegiate Athletic Association (NCAA) Injury Surveillance System (ISS) for all foot and ankle injuries during the 2004-2005 to 2008-2009 seasons. Injuries were analyzed in terms of incidence and using multiple measures of severity (time loss, surgeries, medical disqualifications). This frequency and severity information is summarized in tabular form as well as in a 4 × 4 quantitative injury risk assessment matrix (QIRAM).Results:The rate of foot and ankle injuries was 15 per 10,000 athletic exposures (AEs). Five injuries were found to be responsible for more than 80% of all foot and ankle injuries: lateral ankle ligament sprains, syndesmotic (high ankle) sprains, medial ankle ligament sprains, midfoot injuries, and first metatarsophalangeal joint injuries. Ankle dislocations were found to be the most severe in terms of median time loss (100 days), percentage of surgeries (83%), and percentage of medical disqualifications (94%), followed by metatarsal fractures (38 days, 36%, and 49%, respectively) and malleolus fractures (33 days, 41%, and 59%, respectively). Statistical analysis suggests that the 3 measures of severity are highly correlated (r > 0.94), thereby justifying the use of time loss as a suitable proxy for injury severity in the construction of the QIRAM.Conclusion:Based on the QIRAM analysis, the 5 highest risk injuries were identified based on both incidence and severity (ankle dislocations, syndesmotic sprains, lateral ankle ligament sprains, metatarsal fractures, and malleolus fractures). A better understanding of the relative incidence and severity of these injuries will allow coaches, trainers, and researchers to more effectively focus their preventative interventions.

ACR Appropriateness Criteria Acute Trauma to the Foot

This ACR Appropriateness Criteria article offers imaging triage guidance for several variants of patients presenting with acute foot trauma. Patients meeting inclusion criteria for the Ottawa Rules should undergo a 3-view radiographic series. Diabetic patients with peripheral neuropathy should undergo radiography, even though they do not meet the Ottawa Rules inclusion criteria. Patients with suspected midfoot and/or Lisfranc injury should undergo 3-view radiographs with weight bearing on at least the anterior–posterior view. Patients with suspected Lisfranc injury and normal radiographs should be considered for MRI and CT on a case-by-case basis. MRI or ultrasound could confirm cases of suspected acute tendon rupture. Radiography is the initial imaging modality for suspected plantar plate injury after metatarsal–phalangeal joint injury. Weight-bearing anterior–posterior, lateral, and sesamoid axial views may detect proximal migration of the hallux sesamoids. Ultrasound or MRI can directly evaluate the capsuloligamentous complex, specifically the plantar plate. Radiography can detect radiopaque penetrating foreign bodies, and ultrasound can be helpful in detecting those that are nonradiopaque.The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures, by the panel. In instances in which evidence is lacking or is not definitive, expert opinion may be used to recommend imaging and treatment.

Etiology and Biomechanics of Midfoot (Lisfranc) Injuries in Athletes.

Tarsometatarsal (TMT) dislocations are an uncommon but debilitating athletic injury. When symptomatic midfoot instability persists, an injured athlete frequently requires surgical stabilization and rehabilitation for up to 9 months before returning to full athletic participation. Unfortunately, the limited biomechanical knowledge of this injury prevents prophylactic measures from being developed that could reduce an athlete's risk of injury. The goal of this article is to summarize the literature on TMT dislocations, with a particular emphasis on the relevant biomechanics, in an attempt to clarify the circumstances and mechanisms under which these injuries occur. Since athletic injuries represent only a small portion of all TMT dislocations, other categories of injuries are also considered for the insight they provide. This review first summarizes the anatomy of the TMT joint as well as the clinical details surrounding TMT dislocations. The various hypothesized injury mechanisms are then reviewed with particular attention given to cadaveric studies that investigate these mechanisms. Based on this critical review, gaps in the research related to epidemiologic data, full-scale and component testing, numerical modeling, and countermeasure development, are identified. Only by improving our understanding of the causes and biomechanics can steps be taken to protect athletes from these injuries.

Midterm functional outcome after operative management of midfoot injuries.

Background. Injuries of the midfoot are often missed and therefore underestimated. Early diagnosis and treatment are crucial for the final outcome. The primary aim of this study was to assess the pattern and results of early operative management of mid-foot injuries after a midterm follow up. Material and methods. This study was conducted on 25 patients (19 Males, 6 Females ) with mean age of 34.6 years (range 18-60 years) with mid-foot fracture dislocations who were admitted consecutively at our centre from May 2008 through November 2010. 25 patients fulfilling our inclusion criteria with mid-foot fracture dislocations were included in this study. Mechanism of injury, its pattern and results of operative management of midfoot injuries were assessed after acute management of these fractures on urgent basis. Evaluation of results was done by AOFAS Score. Results. Most common mode of injury was indirect trauma due to fall (n=12) followed by road traffic accident (n=9). Males (n=19) outnumbered females (n=6). The pattern of injuries requiring operative treatment as per our criteria were Lisfranc fracture dislocations (n=22) and navicular fractures (n=3). The mean follow up was 3.2 years and mean AOFAS score at 3.2 years was 78.36, with most patients losing points to pain and decreased recreational function. Conclusion. The Lisfranc fracture dislocations are the most common injuries around midfoot requiring operative treatment, and we believe that operative treatment considerably improves functional outcome in these injuries.