Tarsometatarsal Joint Injuries Research Articles

Trends in management of adult tarsometatarsal joint injuries in a contemporary Australian context: a nationwide study of claims data over 20 years.

Traumatic tarsometatarsal joint (TMTJ) injuries are uncommon, but can cause significant morbidity due to delayed or missed diagnosis. Recent evidence highlights the importance of achieving anatomical reduction via operative management. This study aims to analyse trends in rates of open reduction internal fixation (ORIF) for Lisfranc injuries in Australia according to Nationwide claims data. Claims according to the Medicare Benefits Schedule (MBS) on ORIF of traumatic TMTJ injuries were collated for the period from January 2000 to December 2020. Paediatric patients were excluded. Two negative binomial models were utilized to analyse the trends in TMTJ injuries over time after controlling for sex, age group and population changes. Results were absolute and per 100 000 population. 7840 patients underwent TMTJ ORIF over the period studied. There was a mean yearly increase of 12% (P < 0.001). Age group (P < 0.001) and year (P < 0.001) were significant predictors for TMTJ fixation, whilst sex was not (P = 0.48). Patients older than 65 years were noted to have a 53% lower rate of TMTJ ORIF per person, when compared to the reference group of 25-34 year-olds (P < 0.001). Five-year block analysis revealed increases in rate of fixation for all age groups. Rates of operative fixation for TMTJ injuries are increasing in Australia. This is likely due to improved diagnostics, understanding of optimal treatment goals, and increased orthopaedic subspecialisation. Further studies with clinical and patient reported outcomes, as well as comparing rates of operative intervention to incidence, will be useful.

The First Tarsometatarsal Joint in Lisfranc Injuries.

Lisfranc injuries are among the most debilitating injuries to the foot. Characterization of first tarsometatarsal (TMT) joint involvement in Lisfranc injuries is limited. Multiple studies have indicated that this joint is damaged in a variety of Lisfranc injury patterns, but there is sparse information regarding how often and in what form. A retrospective review was performed of operative Lisfranc fractures from 2010 to 2020 with patients identified by Combined Procedural Terminology codes. Hardcastle and Myerson Lisfranc injury classifications and computed tomography and radiograph characterizations of the first TMT joint were evaluated by 3 foot and ankle fellowship-trained orthopaedic surgeons. Radiographic characteristics were collected. Light's kappa coefficient evaluated interrater reliability for injury classification. Injury mechanism and Lisfranc classification effects on the first TMT joint were further assessed using inferential statistics. Of 71 patients with a Lisfranc injury of which 37 (52%) were high energy, 61 (86%) showed radiographic evidence of first TMT joint injury. A fragment was present in the TMT articular surface in 33 (47%) with median size = 8.7 mm and medial capsular avulsion in n = 25 (35%). Forty-eight patients (68%) had medial/lateral TMT joint incongruence ≥2 mm (median overhang = 4 mm), 21 (30%) had dorsal/plantar incongruence (median overhang = 6 mm). Angulation of TMT articular surfaces ≥5 degrees on the transverse/anteroposterior plane occurred in n = 32 (45%) and in n = 12 (17%) on the sagittal/lateral plane, which significantly differed between classifications (P = .020). The overwhelming majority of Lisfranc midfoot injuries seen at our tertiary referral center had imaging evidence of damage to the first TMT joint (86%), and the incidence may be higher. The most common patterns of first TMT joint involvement we found were joint incongruity, articular surface fractures, angulation of the articular surfaces, and medial capsular ligament avulsion fractures. A better understanding of injuries to the first TMT joint can help orthopaedic surgeons with diagnosis.

Percutaneous Treatment With Bridge Plate and Extra-articular Screws in Low-Energy and High-Energy Lisfranc Injuries

Although there is no consensus regarding surgical treatment of unstable sprains and fractures dislocations of the Lisfranc complex, both anatomic reduction, proper alignment and adequate stabilization of the tarsometatarsal columns are essential when looking for good results. With the advent of minimally invasive surgery, and bearing in mind that the percentages of complications and sequelae despite the good results in reduction quality are still important, we aim to show the clinical and radiographic results over 1-year follow-up obtained by indirect reduction and percutaneous fixation with bridge plate and extra-articular screws in a series of patients with low-energy and high-energy Lisfranc lesions. Eleven patients were operated upon diagnosed with acute tarsometatarsal joint injuries, which showed unstable sprains and/or fracture dislocation with partial articular fracture and a minimum of 1-year follow up. The average age was 30.7 years. The results of the postoperative tomographic controls were as follows: residual joint step average of 0.2 mm, 0.45, and 0 mm in first cuneiform-base of first metatarsal, second cuneiform-base of second metatarsal and third cuneiform-base of third metatarsal, respectively. Anatomical reduction was obtained in the majority of our patients with very good functional results in the evaluated period. Although this is an ongoing investigation, we believe that this method could be taken into account in properly selected patients, even in high-energy injuries. Level of Evidence: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Short-term effectiveness of Endobutton plate in reconstruction of Lisfranc ligament

To observe the short-term effectiveness of Endobutton plate in the reconstruction of Lisfranc ligament in tarsometatarsal joint injury. Between March 2015 and July 2018, 18 patients with tarsometatarsal joint injuries were treated with Lisfranc ligament reconstruction by Endobutton plate. There were 12 males and 6 females with an average age of 32.5 years (range, 16-55 years). The causes of injury were traffic accident in 8 cases, falling from height in 3 cases, crushing by a heavy objective in 4 cases, and spraining in 3 cases. There were 10 cases of Myerson type A, 4 of type B1, 2 of type B2, 1 of type C1, and 1 of type C2. The interval between injury and operation ranged from 3 to 9 days (mean, 4.9 days). X-ray examination was performed regularly after operation to measure the distance between the first and the second metatarsal joints, and the visual analogue scale (VAS) score was used to evaluate the pain relief. At last follow-up, the reduction of tarsometatarsal joint was evaluated by measuring and comparing the height of the affected and healthy arches. The foot function was evaluated according to the American Orthopaedic Foot and Ankle Society (AOFAS) score. The average follow-up time was 15.8 months (range, 10-28 months). All incisions healed by first intention. X-ray reexamination showed that there was no screw loosening or plate fracture. There were significant differences in the distance between the first and the second metatarsal joints and VAS score at 3 months after operation, before removal of the internal fixator, and at last follow-up when compared with preoperative values ( P<0.05). There was no significant difference between the time points after operation ( P>0.05). At last follow-up, there was no significant difference in the arch height between affected foot [(5.3±0.2) mm] and healthy foot [(5.4± 0.3) mm] ( t=1.798, P=0.810). The AOFAS score of foot function was 89.5±7.3 with excellent in 12 cases, good in 4 cases, and fair in 2 cases. The excellent and good rate was 88.9%. The reconstruction of Lisfranc ligament with Endobutton plate can stabilize the tarsometatarsal joint and achieve satisfactory foot function at early stage.

Anatomical Pathology of Subtle Lisfranc Injury

The extent and patterns of Lisfranc joint complex disruption in subtle Lisfranc injuries have not been well clarified. We reviewed the direct intraoperative findings for 87 patients, examined computed tomography images that had been obtained preoperatively for 73 of the patients, and classified the injuries according to the Kaar et al. criteria as the transverse type (instability between the first cuneiform [C1] and the second metatarsal [M2] and between the second cuneiform [C2] and M2) or longitudinal type (instability between C1 and M2 and between C1 and C2). Our patients’ injuries were classified as follows: longitudinal type (38%), transverse type (30%), transverse type and first tarsometatarsal (TMT) joint injury (20%), longitudinal type plus transverse type (7%), longitudinal type and first TMT joint injury (3%), and longitudinal type, transverse type, and first TMT joint injury (2%). In 11 patients, the longitudinal injury extended into the naviculo-first cuneiform joint. In 41 (56%) of the 73 patients for whom CT images were obtained, 1 or more fractures (not counting small avulsion fragments between C1 and M2) were found. Orthopedic surgeons should be aware of the various injury patterns possible in cases of subtle Lisfranc injury.

Percutaneous fixation of Lisfranc joint injuries: A systematic review of the literature

ObjectiveThe aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation. MethodsWe searched in Pubmed and Google Scholar Databases for articles regarding screw percutaneous fixation of Lisfranc injuries. Seven studies in total were found to be compatible to our search, according to PRISMA guidelines. Four of those met the criteria of the review and they were included in the meta-analysis. A total number of 106 patients were separated into five groups according to the type of injury and the mean AOFAS score of each group was calculated. Cases in which percutaneous fixation was converted to open treatment due to poor reduction were not included in the study. In addition we compared the outcome score between types of injury according to Myerson classification as well as between purely ligamentous and osseoligamentous injuries. The characteristics of all seven selected studies, such as kind of screw used for fixation, post operative protocol, complications and outcome are mentioned as well. ResultsAverage AOFAS score was 86,2 for type A, 87,54 for type B, and 85 for type C injuries respectively. In pure dislocation group the average AOFAS score was 86,43 and in fracture dislocation group was 87,36. Good to excellent outcome can be expected in patients with different types of injury according to Myerson classification following percutaneous fixation of lisfranc joint injury. Patients with type B injury or a fracture dislocation injury might have better outcome, although this difference was not found to be statistically significant. ConclusionPercutaneous fixation of tarsometatarsal joint injuries is a relatively simple and safe method of treatment, leading to a good functional outcome, especially for Myerson type B as well as for fracture dislocation type of injuries, provided that an anatomical reduction has been achieved. Level of EvidenceLevel III, Therapeutic Study.

Description and outcome of prosthetic ligament placement for stabilization of medial or dorsomedial tarsometatarsal joint luxation in dogs and cats: 16 cases (2004-2017).

To describe prosthetic ligament placement for reduction and stabilization of medial or dorsomedial tarsometatarsal joint luxation in dogs and cats and to report complications and postoperative outcomes for patients that underwent that procedure. 14 dogs and 2 cats with medial or dorsomedial tarsometatarsal joint luxation. The electronic database of a referral surgery practice was searched to identify records of dogs and cats with tarsometatarsal joint luxation that underwent prosthetic ligament placement between January 2004 and March 2017. For each study subject, information extracted from the medical record included signalment, a description of the tarsometatarsal joint injury, durations of anesthesia and surgery, and intraoperative and postoperative care and complications. Radiographic images were also reviewed. The long-term outcome for study subjects was assessed by administration of a standardized questionnaire to owners. Prosthetic ligament placement successfully stabilized the luxated tarsometatarsal joint in all 16 patients. Six patients developed minor postoperative complications, which included bandage-associated dermatitis or ulceration (n = 5) and orthopedic wire failure (1). No major or catastrophic complications were reported. All 13 owners who completed the questionnaire perceived that the described technique resulted in satisfactory long-term function for their pets. Results suggested that prosthetic ligament placement was a technically simple procedure that achieved satisfactory long-term stabilization of the tarsometatarsal joint in small animal patients with medial or dorsomedial luxation of the joint. Prosthetic ligament placement may be an alternative to arthrodesis for tarsometatarsal joint stabilization in appropriate patients.

Functional Outcomes and Return To Sport With Extraarticular Plating Of Lisfranc Injuries In Athletes

Objectives: Lisfranc injuries are increasingly common among athletes. Tarsometatarsal joint injuries often damage the articular cartilage and increase predisposition for post-traumatic arthritis and functional deformity of the midfoot. Injury-related morbidity in athletes has substantial consequences such as decreased performance and earlier retirement from sports. While open reduction and internal fixation (ORIF) has been established as the standard of care for unstable Lisfranc injuries, there is currently no consensus regarding the optimal technique for stabilization. Extra-articular fixation has been described as a reasonable technique for Lisfranc joint stabilization due to avoidance of iatrogenic articular disruption and subsequent morbidity. The purpose of this study was to assess the pre- and post-operative patient-reported outcomes of athletes with Lisfranc injuries following ORIF using an extra-articular dorsal locking plate. Methods: Following Institutional Review Board (IRB) approval, data was collected prospectively using an institution-based patient-reported outcomes registry. The registry was queried for patients who had undergone open treatment for tarsometatarsal dislocation (CPT 28615) between April 2015 and August 2018. Medical records were reviewed for the following criteria: athlete, 15 - 45 years of age, Lisfranc injury, ORIF, extra-articular dorsal locking plate, and completion of both pre- and post-operative outcomes surveys. 10 athletes were identified. The surveys used were as follows: VAPS, PASS, PROMIS-M, PROMIS-P, SF12-M, SF12-P, FAAM-ADL and FAAM-Sports. A comparison of pre- and post-operative outcomes was performed using paired t-tests. Statistical significance was defined as a p-value &lt;0.05. Results: 10 athletes (5 male, 5 female) with an average age of 18.2 years were analyzed. Sports included football, gymnastics, soccer, hockey, and basketball. Competition levels included high school and college. All athletes had scheduled hardware removal between 3 - 5 months (average 4.4 months) after the initial ORIF. The FAAM-ADL scores (Δ42.49, p &lt;0.0174) improved significantly at 6-months follow-up. The improvement of FAAM-ADL scores continued to trend positively for up to 1-year post-operatively; however, there was insufficient data to analyze for significance. There was no statistical significance observed between pre- and post-operative VAPS, PASS, PROMIS-M, PROMIS-P, SF12-M, SF12-P and FAAM-Sports scores at 6-months follow-up. 100% of athletes returned to sport at an average of 6 months. Conclusion: In athletes, extra-articular dorsal plate fixation of the Lisfranc joint demonstrates improvement in post-operative patient reports of function. Broad-statistical significance across all patient-reported measures was likely limited due to the number of participants. Patient-reported outcomes may serve as a guide to assess athlete progress during the post-operative period. Further studies are needed to compare the long-term outcomes of Lisfranc injuries in athletes following various methods of fixation.

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.

Classifying the Lisfranc injury: Literature overview and a new classification

Summary Introduction Injuries to the tarsometatarsal (Lisfranc) joint cover a broad range from subtle, ligamentous injuries to complex fracture-dislocations with severe soft tissue trauma. Almost all existing classifications for injuries at the tarsometatarsal joint either describe the direction of displacement or are based on the trauma mechanism as recollected by the patient. In the current study the literature is reviewed to obtain insight in the existing classifications regarding tarsometatarsal joint injuries (Lisfranc injuries). A new classification is presented based on biomechanics and injury severity. Material and method The electronic databases up to May 1st 2018 of ‘Pubmed Medline’, ‘EMbase’, and ‘Google Scholar’ were searched. Expert consensus was reached on a new classification proposal. Results Based on the literature on biomechanics at the tarsometatarsal level, the foot is divided into a medial (M), central (C) and lateral (L) column. A simple classification is proposed based on the severity of the damage to the tarsometatarsal joint per column. The different grades of injury are: 0, not involved; 1, pure ligamentous injury; 2, simple fracture; 3, comminuted fracture. Conclusion The proposed classification allows for classification of all types of injury ranging from subtle to frank fracture-dislocations. The next step will have to be to validate the classification using inter- and intra-observer agreement.

Anatomy of the Lateral Plantar Ligaments of the Transverse Metatarsal Arch

Category: Midfoot/Forefoot Introduction/Purpose: The anatomy of the Lisfranc complex is well understood. In contrast, the lateral tarsometatarsal ligamentous structures are under-investigated. Our study aimed to identify the plantar ligamentous structures of the lateral tarsometatarsal joints and their significance in transverse metatarsal arch injuries. Methods: We examined 10 cadaveric lower limbs that had been preserved for dissection at the Human Anatomy and Resource Centre at Liverpool University in a solution of formaldehyde. The lower limbs were carefully dissected to identify the ligamentous structures of the plantar aspect of the transverse metatarsal arch. Results: In all specimens, the long plantar ligament blended with a transverse metatarsal ligament spanning from the 2nd to the 5th metatarsal. This transverse metatarsal ligament formed the basis of the roof and distal aspect of the peroneus longus canal. The separate long plantar ligament formed the floor of the peroneus longus canal. In addition, separate intermetarsal ligaments were identifiable connecting each metatarsal. The long plantar ligament provides a connection through the transverse metatarsal ligament, connecting the transverse and longitudinal arches of the foot Conclusion: The plantar ligamentous structures of the lateral tarsometatarsal joints are a combination of individual intermetatarsal ligaments and a transverse metatarsal ligament. This explains the homogenous nature of a divergent tarsometatarsal joint injury and why middle and lateral columns move as one. It also has clinical significance in the observation that in some cases lateral column instability can be overcome when the middle column is stabilised.

Effects of multi-block reconstructive plate on the treatment of complex tarsometatarsal joint injury

Objective To evaluate the effect of multi-plate reconstruction plate in the treatment of partial complex tarsometatarsal joint injury injuries. Methods Seven patients treated complex tarsometatarsal joint injuries with multi-plate reconstruction plate in Nanjing Hospital Affiliated to Nanjing Medical University from September 2014 to July 2016 were selected in this study.According to Myerson classification, 3 cases were A type, 3 cases were B type, 1 case was C type.The therapeutic effects were observed. Results The patients were followed up for 6-12 months, with an average of (8.6±2.0) months.According to the foot scoring criteria in American Orthopedic Foot and Ankle Society (AOFAS), the function of the foot was evaluated, 3 cases were in excellent condition, 4 cases were in good condition. Conclusion In the case of multiple metatarsal fractures of the metatarsal base involved in the joint surface, the use of multiple reconstructive plates for joint fixation reduces the iatrogenic damage of the joint surface.The fixation effect and the functional recovery are satisfactory Key words: Tarsometatarsal joint injury; Reconstructive plate; Foot scoring standard

Finite element analysis of locking plate and 1/4 tubular plate for first tarsometatarsal joint fracture-dislocation.

ObjectiveThe optimal plate for fixation of tarsometatarsal joint injuries is controversial. The objective of this study was to compare the biomechanical characteristics between a locking plate and 1/4 tubular plate for first tarsometatarsal joint fracture-dislocation.MethodFinite element analysis was used after establishment of a first tarsometatarsal joint fracture-dislocation model. Two implant simulations using a locking plate and five-hole 1/4 tubular plate were designed to simulate fixation of the fracture-dislocation. The displacement of the first tarsometatarsal articular surface and the stress distribution in the implants were calculated.ResultsA 700-N load was applied to both models. The minimum displacement of the articular surface in the locking plate and 1/4 tubular plate model was 0.6471 mm and 0.3833 mm, respectively. The maximum principal stress in the locking plate and 1/4 tubular plate was 1.212 × 103 MPa and 1.107 × 103 MPa, respectively.ConclusionUse of a 1/4 tubular plate is recommended for fixation of first tarsometatarsal joint fracture-dislocation after consideration of other factors such as economical issues.

Management of Tarsometatarsal Joint Injuries.

Joint disruptions to the tarsometatarsal (TMT) joint complex, also known as the Lisfranc joint, represent a broad spectrum of pathology from subtle athletic sprains to severe crush injuries. Although injuries to the TMT joint complex are uncommon, when missed, they may lead to pain and dysfunction secondary to posttraumatic arthritis and arch collapse. An understanding of the appropriate anatomy, mechanism, physical examination, and imaging techniques is necessary to diagnose and treat injuries of the TMT joints. Nonsurgical management is indicated in select patients who maintain reduction of the TMT joints under physiologic stress. Successful surgical management of these injuries is predicated on anatomic reduction and stable fixation. Open reduction and internal fixation remains the standard treatment, although primary arthrodesis has emerged as a viable option for certain types of TMT joint injuries.

Surgical treatment for open tarsometatarsal joint injury

To discuss the surgical method and clinical efficacy for open tarsometatarsal joint injuries. From March 2011 to January 2015, 21 patients with open tarsometatarsal joint injuries were treated with stage-surgery method, including 14 males and 7 females with an average age of 45.6 years old ranging from 20 to 75 years. Injury site occurred in the left foot of 13 cases and right foot of 8 cases. Traffic injury was in 5 cases, crush injury in 6 cases, heavy crushing was in 10 cases. According to Myerson to classify for tarsometatarsal joint injury, 5 cases were type B2, 9 cases were type C1, and 7 cases were type C2. And according to Gustilo to typing for soft tissue injury, 5 cases were type IIB, 10 cases were type IIIA, 6 cases were type IIIB. Fracture healingand complications were observed after operation and clinical effects were evaluated according to the midfoot score of AOFAS. All the patients were followed up from 11 to 40 months with an average of 16.2 months. The fracture healing time was from 10 to 16 weeks with an average of 12.3 weeks. No complications such as deep infection, nonunion and osteomyelitis were found. Midfoot score of AOFAS at last follow-up was 83.0±14.9, 9 cases got excellent results, 8 good, 2 fair, 2 poor. Two patients complicated with severe traumatic arthritis once again underwent tarsometatarsal arthrodesis. For the treatment of open tarsometatarsal joint injury, reasonable debridement, comprehensive assessment for the soft tissue injury, correctly grasp the surgical indications and time of internal fixation, can reduce the incidence of deep infection and osteomyelitis.

Results of Displaced Lisfranc Injuries with Open Reduction and Fixation with K-Wires

Background: The Lisfranc injury is an injury of the foot in which one or more metatarsal bones are displaced from the tarsal bones. Due to their low incidence and complexity, these injuries are often missed on initial evaluation. Prompt recognition and then anatomic reduction and stabilization gives best outcomes post treatment.Aim: The study aimed to compare short-term treatment results for tarso-metatarsal joint injuries with treatment outcomes and compare it with type of injury per classification.Methods: This was a prospective observational, analytical hospital based study. The subjects included in the study were classified according to radiological findings and treated with open reduction and K-wire fixation. Study subjects were immobilized for six weeks. Weight bearing was progressed slowly. Short term result was calculated by American orthopaedic foot and ankle society score (AOFAS) at six months. Results: Of the nine cases included in the study, low energy fall, five (55.55%) was commoner cause for injury followed by high energy road traffic accident (RTA) in four (44.44%) patients. Six fractures (66.67%) were of type A while, three (33.3%) were type B. Average day from injury to surgery was 3.11 (range 2-5). AOFAS Score calculated in six months average was 82.44(SD±12.79). In patients with type A injury mean AOFAS score was 89(SD±2.6), while in patients with type B injury had mean of 69.33(SD±15.82). The AOFAS score difference for the group A and B was statistically significant (P&lt;0.05). Conclusions: Lisfranc injuries are life changing injuries as scores of AOFAS get lower even after 6 months of injury. Patients with type B injuries have poorer outcome than type A injuries.JNGMC Vol. 13 No. 2 December 2015, Page: 35-37

Is Pes Cavus Alignment Associated With Lisfranc Injuries of the Foot?

Lisfranc (tarsometatarsal joint) injuries are relatively rare, accounting for less than 1% of all fractures, and as many as 20% of subtle Lisfranc injuries are missed at the initial patient presentation. An undiagnosed Lisfranc injury can have devastating consequences to the patient. Therefore, any factor that can raise a clinician's index of suspicion to make this diagnosis is potentially important. The cavus foot has been associated with various maladies of the lower extremity, but to our knowledge, it has not been reported to be associated with Lisfranc injury. Do patients who experience a low-energy Lisfranc injury have greater talar head coverage and a greater talo-first metatarsal angle than control subjects? A retrospective, case-control study was conducted from September 2011 to December 2014 to identify patients diagnosed and treated for a low-energy Lisfranc injury. Twenty-three adult patients with an average age of 42.6 years (SD, 16.3 years) were identified and compared with 61 adult control subjects with an average age of 49.4 years (SD, 14.1 years). Control subjects came from the practice of a fellowship-trained foot and ankle orthopaedic surgeon. Control subjects underwent a history and physical, clinical examination, and diagnostic imaging to confirm that they had no prior foot disorder, no prior foot surgeries, were within 3 years of age of a patient with a Lisfranc injury, and were independent ambulators. Two authors (DSD and JDP) measured the talonavicular and talo-first metatarsal angles on weightbearing AP and lateral radiographs of the foot. The intrarater reliability and interrater reliability for the talo-first metatarsal angle and the talonavicular angle showed high agreement. The intrarater intraclass correlation coefficients (ICC) of the talo-first metatarsal angle were 0.94 (95% CI, 0.91-0.96) and 0.93 (95% CI, 0.9-0.96). For the talonavicular angle the ICCs were 0.83 (95% CI, 0.75-0.89) and 0.88 (95% CI, 0.81-0.92) for Raters 1 and 2 respectively. The interrater ICCs were 0.91 (95% CI, 0.69-0.96) for the talo-first metatarsal angle and 0.9 (95% CI, 0.85-0.94) for the talonavicular angle. The patients and controls were compared to determine if the patients who sustained a Lisfranc injury were more likely to have a pes cavus foot alignment. We performed a mixed modeling analysis to control for potential cofounding variables and determine if there was an association of Lisfranc injury with the talo-first metatarsal angle and the talonavicular angle. After controlling for confounding variables such as the effect of the measurement round effect and the effect of the rater, our repeated measures analysis via mixed model showed patients were associated with a higher talo-first metatarsal angle than control subjects (adjusted least square mean for patients = 3.05; for controls = -2.65; mean difference, 5.7; p = 0.001). Repeated measures analysis via mixed model showed that patients also were associated with a more positive talonavicular angle than control subjects (adjusted least square mean for patients = -4.83, for controls = -11; mean difference, 6.17; p = 0.002). Patients with Lisfranc injuries had a higher mean talo-first metatarsal angle than did control subjects (1.9° ± 7.9° versus -2.2° ± 7.3°; mean difference, 4.1°; 95% CI, -7.7° to -0.5°; p = 0.028), and less talar uncovering (-4.2° ± 9.7° versus -11° ± 8°; mean difference, 6.7°; 95% CI, -6.7° to -10.8°; p = 0.001). We found that cavus midfoot alignment was more prevalent among patients with Lisfranc injuries than among individuals with no foot injury or disorder. Although this does not suggest that cavus alignment causes or predisposes patients to this injury, we believe the finding is important because this provides a radiographic parameter that clinicians can use to raise their index of suspicion for a Lisfranc injury and aggressively pursue this diagnosis. Future studies would benefit from obtaining contralateral foot imaging at the time of injury in all patients with Lisfranc injury or prospectively following patients with foot imaging and recording the incidence of future foot injury. Level III, prognostic study.

Tarsometatarsal (Lisfranc) Joint Injury in an Athlete With Persistent Foot Pain

The patient was a 20-year-old female ultimate frisbee player who felt a "pop" in her left foot with resultant pain and bruising along the plantar aspect of her midfoot. She was seen by an orthopaedic physician, who ordered standard radiographs that were found to be unremarkable. Although initial non-weight-bearing films were normal, these findings do not rule out tarsometatarsal joint injury. Following presentation to physical therapy 4 months after the initial injury, the patient was referred to a sports medicine physician. Weight-bearing radiographs and magnetic resonance imaging were ordered and confirmed a high-grade Lisfranc ligament tear. J Orthop Sports Phys Ther 2016;46(6):494. doi:10.2519/jospt.2016.0408.

Outcomes of Lisfranc Injuries in the National Football League

Background: Tarsometatarsal (Lisfranc) joint injuries commonly occur in National Football League (NFL) competition; however, the career effect of these injuries is unknown. Purpose: To define the time to return to competition for NFL players who sustained Lisfranc injuries and to quantify the effect on athletic performance. Study Design: Case-control study; Level of evidence, 3. Methods: Data on NFL players who sustained a Lisfranc injury between 2000 and 2010 were collected for analysis. Outcomes data included time to return to competition, total games played after season of injury, yearly total yards and touchdowns for offensive players, and yearly total tackles, sacks, and interceptions for defensive players. Offensive power ratings (OPR = [total yards/10] + [total touchdowns × 6]) and defensive power ratings (DPR = total tackles + [total sacks × 2] + [total interceptions × 2]) were calculated for the injury season and for 3 seasons before and after the injury season. Offensive and defensive control groups consisted of all players without an identified Lisfranc injury who competed in the 2005 season. Results: The study group was composed of 28 NFL athletes who sustained Lisfranc injuries during the study period, including 11 offensive and 17 defensive players. While 2 of 28 (7.1%) players never returned to the NFL, 26 (92.9%) athletes returned to competition at a median of 11.1 (interquartile range [IQR], 10.3-12.5) months from time of injury and missed a median of 8.5 (IQR, 6.3-13.0) regular-season games. Analysis of pre- and postinjury athletic performance revealed no statistically significant changes after return to sport after Lisfranc injury. The magnitude of change in median OPR and DPR observed in offensive and defensive Lisfranc-injured study groups, −34.8 (IQR, −64.4 to 1.4) and −13.5 (−30.9 to 4.3), respectively, was greater than that observed in offensive and defensive control groups, −18.8 (−52.9 to 31.5) and −5.0 (−22.0 to 14.0), respectively; however, these differences did not reach statistical significance (P = .33 and .21, respectively). Evaluation of the durability of injured players after the season of injury revealed no statistically significant difference in career length compared with controls. Conclusion: More than 90% of NFL athletes who sustained Lisfranc injuries returned to play in the NFL at a median of 11.1 months from time of injury. Offensive and defensive players experienced a decrease in performance after return from injury that did not reach statistical significance compared with their respective control groups over a similar time period.

Outcomes of Lisfranc Injuries in the National Football League

Objectives:Tarsometatarsal (Lisfranc) joint injuries commonly occur in American professional football competition; however, the career impact of these injuries is unknown. This study aims to define the time to return to competition for professional football players who sustained Lisfranc injuries and to quantify their effect on athletic performance.Methods:Data on National Football League (NFL) players who sustained a Lisfranc injury during a ten-year time period (2000-2010) were collected for analysis. Recorded demographic variables included age, experience, position, and operative vs. non-operative management. Outcomes data collected for offensive players (running backs, wide receivers, tight ends) included time to return to competition and yearly total yards and touchdowns. Outcomes data collected for defensive players (defensive linemen, linebackers, defensive backs) included time to return to competition and yearly total tackles, sacks, and interceptions. Offensive power ratings (OPR=total yards/10 + total touchdowns x6) and defensive power ratings (DPR=total tackles + total sacks x2 + total interceptions x2) were calculated for the injury season and for 3 seasons before and after the injury season. Offensive and defensive control groups consisted of all players of similar positions without an identified Lisfranc injury that competed in the 2005 season.Results:Lisfranc injuries were identified in 28 NFL athletes in the study period, including 11 offensive players and 17 defensive players. While 2 of 28 (7.1%) players never returned to the NFL, the remaining 26 (92.9%) athletes returned to competition at a median 11.1 (interquartile range: 10.3-12.5) months from time of injury and missed a median 8.5 (6.3-13.0) NFL regular season games. Players treated non-operatively were noted to have an earlier return to play with a median absence from play of 6.2 (1.9-10.7) months and 7.0 (4.5-8.0) games compared to those treated operatively who returned after a median 11.6 (10.7-12.6) months (p=0.02) and 10.0 (7.0-13.3) games missed (p=0.09). Analysis of pre- and post-injury athletic performance revealed no statistically significant changes following return to sport after Lisfranc injury. The magnitude of change in median OPR for 3 seasons prior to index season compared to 3 seasons after index season observed in the Lisfranc-injured offensive study group, -34.8 (-64.4-1.4), was greater than that observed in the offensive control group, -18.8 (-52.9-31.5); however, these differences did not reach statistical significance (p=0.33). Similarly, the magnitude of change observed in the Lisfranc-injured defensive study group, -13.5 (-30.9-4.3), was greater than that observed in the defensive control group, -5.0 (-22.0-14.0); however, these differences also did not reach statistical significance (p=0.21).Conclusion:Greater than 90% of NFL athletes who sustained Lisfranc injuries returned to play in the NFL at a median 11.1 months from time of injury. Operative treatment was associated with a longer time to return; however, this is a potential surrogate for greater injury severity. Offensive and defensive players experienced a decrease in performance after return from injury that did not reach statistical significance when compared to their respective control groups over a similar time period.