Nonunion Rate Following Primary Arthrodesis for Acute Lisfranc Injuries.

Injury to the tarsometatarsal joint (TMT) results in instability throughout the midfoot that does not often improve with conservative management. If instability is identified, surgical intervention is frequently recommended, either open reduction and internal fixation (ORIF) or primary arthrodesis (PA). These 2 treatment options have been compared in the literature multiple times, often reporting similar outcomes. Due to this, as well as the need for subsequent hardware removal after ORIF has led many surgeons towards PA at the index surgery. Concern for nonunion is a leading concern with surgeons who advocate instead for ORIF. The purpose of this study is to review patients who underwent PA and observe nonunion rates. Nonunion at the TMT has been previously studied, but only in the chronic setting. We performed a retrospective study of 34 patients who had PA in the management of an acute Lisfranc injury. The average age in our study was 43.9 years old (range 19-72, SD 17.4) with an average follow-up of 9.4 months (range 4-33, SD 6.2). Radiographs were evaluated for signs of nonunion at regular postoperative intervals. Within the patients included in the study, a total of 71 TMT joints were fused. Overall successful fusion rate was 95.8% at an average of 7.9 weeks (range 6-12, SD 1.4) postoperatively. Individual nonunion rates at the first, second, and third TMT were 0%, 1.4% and 2.8% respectively. Our study demonstrates that primary arthrodesis provides a predictable outcome with low nonunion rates in the management of acute Lisfranc injury.

Chopart Joint Injuries: Assessment, Treatment, and 10-Year Results.

OBJECTIVES: To investigate injury patterns and long-term outcomes of midtarsal (Chopart) injuries in a sizeable number of patients. DESIGN: Prospective study. SETTING: Level 1 trauma center. PATIENTS: One hundred twenty-two patients (average age 37.6 years) with 128 Chopart injuries over a 15-year period, 27% of who were polytraumatized. In 47%, more than 1 of the 4 bones of the midtarsal joint was fractured. The navicular and cuboid were fractured most often. Purely ligamentous dislocations occurred in 4%. INTERVENTIONS: Operative treatment tailored to the individual fracture pattern was performed in 91.4%. MAIN OUTCOME MEASUREMENTS: Foot Function Index, American Orthopaedic Foot and Ankle Society score, SF-36 physical (PCS) and mental component summary (MCS). RESULTS: Seventy-three patients with 75 Chopart injuries were available for follow-up at an average of 10.1 years. The Foot Function Index averaged 26.9, the American Orthopaedic Foot and Ankle Society score averaged 71.5, and the SF-36 PCS and MCS averaged 43.5 and 51.2, respectively. Negative prognostic factors were a high injury severity score, work-related accidents, open and multiple fractures, purely ligamentous dislocations, staged surgery, delay of treatment >4 weeks, postoperative infection, and primary or secondary fusion. Open reduction and internal fixation led to significantly better results than attempted closed reduction and percutaneous fixation. Radiographic signs of posttraumatic arthritis were observed in 93%, but only 4.7% of cases required a late fusion at the Chopart joint. CONCLUSIONS: Chopart joint injuries lead to functional restrictions in the long term. Purely ligamentous dislocations have the worst prognosis, whereas fractures of a single bone have a favorable outcome after anatomic reduction and internal fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Validity and internal consistency of the American Orthopaedic Foot and Ankle Society Midfoot Scale in patients with Lisfranc injury.

BACKGROUND: The American Orthopaedic Foot and Ankle Society (AOFAS) Midfoot Scale is an extensively used outcome measure instrument for evaluating outcomes after foot and ankle surgery or trauma. METHODS: In total, 117 patients with Lisfranc injury completed the AOFAS Midfoot Scale and the Visual Analogue Scale Foot and Ankle (VAS-FA) instruments. Internal consistency (correlation between different items), floor and ceiling values, convergent validity, item threshold distribution, and the coverage (item difficulty) of the AOFAS Midfoot scale were tested. RESULTS: AOFAS Midfoot Scale had high convergent validity and acceptable internal consistency (Cronbach's alpha >0.70). The ceiling effect was confirmed. The person-item distribution indicated that the scale had a lack of coverage and targeting in our sample. CONCLUSIONS: Our data suggests that the AOFAS Midfoot Scale has acceptable validity and internal consistency. However, due to the lack of coverage and targeting, it should not be the primary outcome measure to be used to evaluate the outcomes after Lisfranc injury in the future studies.

Lisfranc injuries: Incidence, mechanisms of injury and predictors of instability.

BACKGROUND: In Lisfranc injuries the stability of the tarsometatarsal joints guides the treatment of the injury. Determining the stability, especially in the subtle Lisfranc injuries, can be challenging. The purpose of this study was to identify incidence, mechanisms of injury and predictors for instability in Lisfranc injuries. METHODS: Eighty-four Lisfranc injuries presenting at Oslo University Hospital between September 2014 and August 2015 were included. The diagnosis was based on radiologically verified injuries to the tarsometatarsal joints. Associations between radiographic findings and stability were examined. RESULTS: The incidence of Lisfranc injuries was 14/100,000 person-years, and only 31% were high-energy injuries. The incidence of unstable injuries was 6/100,000 person-years, and these were more common in women than men (P = 0.016). Intraarticular fractures in the two lateral tarsometatarsal joints increased the risk of instability (P = 0.007). The height of the second tarsometatarsal joint was less in the unstable injuries than in the stable injuries (P = 0.036). CONCLUSION: The incidence of Lisfranc injuries in the present study is higher than previously published. The most common mechanism of injury is low-energy trauma. Intraarticular fractures in the two lateral tarsometatarsal joints, female gender and shorter second tarsometatarsal joint height increase the risk of an unstable injury. LEVEL OF EVIDENCE: Level III, cross-sectional study.

Comparative analysis of clinical outcomes of fixed-angle versus variable-angle locking compression plate for the treatment of Lisfranc injuries.

BACKGROUND: Fixed-angle locking compression plate (LCP) and variable-angle LCP are utilized for internal fixation of Lisfranc injuries. However, studies regarding the difference of clinical outcomes of these two plates are limited. The purpose of present study was to compare postoperative outcomes between these two plate types in Lisfranc injuries. METHODS: A total of 45 consecutive patients (22 patients with fixed-angle LCP and 23 patients with variable-angle LCP) who underwent surgical treatment for Lisfranc injury were reviewed for this retrospective study. The Foot Function Index (FFI), numerical rating scale (NRS) for pain, development of complications, operative time, and patient satisfaction for current activity were compared. RESULTS: There were no significant differences in FFI and NRS for pain at three months and 12 months following surgery. Postoperative complication rate was similar between two groups. Patients with variable-angle LCP had an 18 min shorter mean length of operation (p = 0.040). Patient satisfaction for current activity was not differ between two groups. CONCLUSIONS: The use of variable-angle LCP for treatment of Lisfranc injuries did not show superiority in functional outcomes, pain, complication rates, or patient satisfaction to fixed-angle LCP, but operative time was shorter with variable-angle LCP. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Rates of Displacement and Patient-Reported Outcomes Following Conservative Treatment of Minimally Displaced Lisfranc Injury.

BACKGROUND: While surgery is indicated in Lisfranc fracture-dislocations, the natural history and optimal management of minimally displaced injures are unclear. The aim of this study was to define the rate of subsequent displacement and to determine the clinical outcome after conservative treatment of minimally displaced Lisfranc injuries. METHODS: Over a 5-year period (2011-2016), 26 consecutive patients with minimally displaced Lisfranc injuries presenting to a single university teaching hospital were identified retrospectively using hospital electronic records. Patient demographics, injury mechanism, and radiological outcomes were recorded. Patient-reported outcome scores (PROMS) were collated at least 1 year postinjury and included the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ). RESULTS: The rate of displacement was 54% (14/26). The median time to displacement was 18 days (range, 2-141 days). Forty-six percent (12/26) of the Lisfranc injuries remained minimally displaced after 12 weeks of conservative treatment. Initial weightbearing status was not associated with the risk of subsequent displacement (P = .9). At a mean follow-up of 54 months, PROMS were comparable between patients whose injury remained minimally displaced and those that required surgery for further displacement, despite the delay to surgery (AOFAS 78.0 vs 75.9, MOXFQ 24.8 vs 26.3, P > .1). CONCLUSION: There was a high rate of displacement after initial conservative management of the minimally displaced Lisfranc injuries. Subsequent surgical management of displaced injuries resulted in outcomes comparable to those that remained minimally displaced. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Is Routine Hardware Removal Following Open Reduction Internal Fixation of Tarsometatarsal Joint Fracture/Dislocation Necessary?

Open reduction internal fixation (ORIF) is an accepted treatment for displaced tarsometatarsal joint (TMTJ) fracture dislocations. In general, hardware is routinely removed after 4 months to allow restoration of joint motion and avoid complications of hardware failure. Because few studies report outcomes of TMTJ fractures with retained hardware, there is little consensus regarding the optimal time for hardware removal or if hardware retention leads to adverse outcomes. We retrospectively reviewed the radiographic outcomes of retained hardware after ORIF of TMTJ fractures/dislocations in 61 patients. The mean age at the time of operation was 37.3 ± 14.9 years. ORIF was performed with 3.5 fully threaded cortical screws. Assessment of clinical and radiographic results was performed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgical treatment. Out of the 61 patients that were included in this study, only 2 demographic variables demonstrated a trend for an adverse outcome. Older age correlated with lost reduction and elevated body mass index correlated with hardware failure. The presence of diabetes was correlated with an increased risk of postoperative infection but not hardware failure. During our follow-up period there were 49 patients (80.3 %) without failure of fixation. In conclusion, our study suggests that routine removal of hardware following open reduction and internal fixation of Lisfranc injuries in patients may not be necessary.

Osteochondral Defect of the Calcaneocuboid Joint: A Case Study.

Osteochondral lesions (OCLs) are injuries affecting the articular cartilage surface of a joint. OCLs are well reported in the literature to affect the knee, talus, tibia, navicular, and first metatarsal. This rare case of a bipolar osteochondral lesion of the cuboid and calcaneus presented as lateral heel pain after a traumatic injury. After an unsuccessful course of conservative therapy, the lesion was treated with curettage and application juvenile particulate cartilage allograft. Eight months postoperatively, the patient was ambulating in supportive shoe gear without pain. The mechanism of injury leading to calcaneocuboid joint osteochondral lesions is not clearly understood. It is also questionable whether anatomic variances are contributory. Regardless of causality, OCLs should be included in the differential diagnoses for patients presenting with calcaneocuboid joint or lateral hindfoot pain.

Injury Pattern in Ligamentous Lisfranc Injuries in Competitive Athletes.

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

Arthroscopic Microfracture for Traumatic Arthritis of Lateral Tarsometatarsal Joints A Case Report.

Conservative treatment is generally successful in treating early tarsometatarsal joint arthritis. However, if such treatment fails, invasive arthrodesis or arthroplasty may be needed. Arthroscopy is a less invasive alternative and can provide a precise diagnosis of early osteoarthritis or cartilage injury. Furthermore, arthroscopic treatments such as microfracture, chondroplasty, or loose-body removal are expected to delay progression of the osteoarthritis. We describe a 52-year-old man with early tarsometatarsal joint arthritis after calcaneal fracture healing who underwent a successful arthroscopic microfracture for cartilage defects. Arthroscopic findings show cartilage defects on the fourth and fifth tarsometatarsal joints. The patient underwent shaving and microfracture. The patient continues to experience effective symptom relief 3 months after surgery.

Cross-Sectional Area Measurement of the Central Tarsometatarsal Articulation: A Review of Computed Tomography Scans.

Currently, disagreement exists regarding the superior method for repairing a ligamentous Lisfranc injury regarding whether to use arthrodesis or open reduction internal fixation. The 2 procedures differ in the amount of articular cartilage destroyed. Arthrodesis removes all the articular cartilage, and open reduction internal fixation places transarticular screws, essentially destroying a portion of cartilage. We performed a review of 30 consecutive computed tomography scans that included both foot length and undamaged first, second, and third tarsometatarsal joints to quantify the amount of articular surface area destroyed by placement of standardized 4-mm diameter screws. Measurements were performed using a freeform tool. The calculated surface area of the screws was subtracted from the measured surface area of the joint to yield the amount of surface area occupied by the screws. Our results demonstrated that the average amount of articular surface area destroyed in the first, second, and third tarsometatarsal joints was 4.87%, 4.79%, and 4.86% respectively, with a standard deviation of <1% for each of the joints. Our results have demonstrated that screw placement accounts for only a small percentage of articular surface destroyed. They also showed that the articular surface damage was comparable among the first 3 tarsometatarsal joints. Additionally, our results were similar to the articular surface area calculated from cadaveric specimens in a previous biomechanical study, demonstrating that computed tomography can allow for reliable and accurate assessments of articular surface areas in the foot.

Reoperation Rate Differences Between Open Reduction Internal Fixation and Primary Arthrodesis of Lisfranc Injuries.

BACKGROUND: Controversy persists as to whether Lisfranc injuries are best treated with open reduction internal fixation (ORIF) versus primary arthrodesis (PA). Reoperation rates certainly influence this debate, but prior studies are often confounded by inclusion of hardware removal as a complication rather than as a planned, staged procedure inherent to ORIF. The primary aim of this study was to evaluate whether reoperation rates, excluding planned hardware removal, differ between ORIF and PA. A secondary aim was to evaluate patient risk factors associated with reoperation after operative treatment of Lisfranc injuries. METHODS: Between July 1991 and July 2016, adult patients who sustained closed, isolated Lisfranc injuries with or without fractures and who underwent ORIF or PA with a minimum follow-up of 12 months were analyzed. Reoperation rates for reasons other than planned hardware removal were examined, as were patient risk factors predictive of reoperation. Two hundred seventeen patients met enrollment criteria (mean follow-up, 62.5 ± 43.1 months; range, 12-184), of which 163 (75.1%) underwent ORIF and 54 (24.9%) underwent PA. RESULTS: Overall and including planned procedures, patients treated with ORIF had a significantly higher rate of return to the operation room (75.5%) as compared to those in the PA group (31.5%, P < .001). When excluding planned hardware removal, however, there was no difference in reoperation rates between the 2 groups (29.5% in the ORIF group and 29.6% in the PA group, P = 1). Risk factors correlating with unplanned return to the operation room included deep infection ( P = .009-.001), delayed wound healing ( P = .008), and high-energy trauma ( P = .01). CONCLUSION: When excluding planned removal of hardware, patients with Lisfranc injuries treated with ORIF did not demonstrate a higher rate of reoperation compared with those undergoing PA. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

A Novel Technique for Extracapsular Repair of the Intertarsal Joint in a Duck.

The intertarsal joint is a synovial roll-and-glide joint. Ligament damage and luxations of this joint are often the result of traumatic injury or growth deformities and result in significant functional impairment. A 9-month-old female Pekin duck ( Anas platyrhynchos domesticus) was examined because of progressive, nonweight-bearing lameness of the left leg. Moderate effusive swelling was present at the level of the left intertarsal joint, without radiographic evidence of bone involvement. The duck failed to respond to nonsteroidal anti-inflammatory medications and analgesia and was diagnosed with rupture of the medial collateral ligament. Extracapsular surgical correction using bone tunnels and circumferential nylon suture on the medial aspect of the intertarsal joint led to a complete clinical resolution with normal return to function 2 weeks after surgery. This report reviews the anatomy and function of the intertarsal joint in the duck and details a simple extracapsular repair technique useful in the correction of collateral ligament rupture in this joint of ducks.

Stabilization of the Fourth Metatarsal-Cuboid Lateral Lisfranc Injury: Early Results of an Innovative Technique Using Suture Anchors.

This report presents an innovative surgical technique for the correction of cuboid-metatarsal subluxation at the level of the lateral Lisfranc joint. This stabilization technique reinforces the dorsal fourth tarsometatarsal ligament by incorporating sutures and anchors, establishing a more stable joint. The data from 5 female patients undergoing stabilization using a suture anchor construct were reviewed. All 5 patients were able to resume their activities, including the adolescent athletes. Anatomic reconstruction of the dorsal fourth tarsometatarsal ligament complex can lead to full mechanical and functional stability, which ultimately allows for a return to activity, even in highly demanding sports and athletes.

[A rare case of internal astragalo-scapho-calcaneal dislocation]. / Un cas rare de luxation astragalo-scapho-calcanéenne interne.

We here report the case of a young patient presenting with sports-related internal astragalo-scapho-calcaneal dislocation. The patient underwent orthopedic treatment with good clinical and radiological outcome.

Talonavicular Dislocation-What Lies Beneath?

BACKGROUND: The talonavicular joint is a rare site of dislocation. Its etiology varies and can be the result of either acute trauma or a chronic degenerative process that most commonly occurs in patients with rheumatoid arthritis or Charcot arthropathy. Our aim is to highlight the relationship between the underlying pathology of talonavicular dislocations and the final outcome in the case of operative management. METHODS: We present three cases of talonavicular dislocation with the dislocation itself as the only common denominator, and a completely different etiology, natural history, treatment, and prognosis among them. RESULTS: There was one case of a traumatic talocalcaneonavicular dislocation in a healthy individual, one case in a rheumatoid arthritis patient, and one case in a patient with diabetes mellitus. All patients were treated surgically. The outcomes were excellent, fair, and poor, respectively. CONCLUSIONS: Among many factors that influence prognosis, it is equally critical to evaluate the overall background in which the dislocation occurs so as to apply the suitable treatment. The surgeon not only needs to treat the local incident but also appreciate the general medical condition to provide the best final outcome to the patient.

Did Failure Occur Because of Medial Column Instability That Was Not Recognized, or Did It Develop After Surgery?

Medial column instability is a primary deforming force in the setting of pes planovalgus deformity. Consideration for medial column stabilization only after correction of the hindfoot deformity may result in creating a rigid hindfoot, compromising clinical outcomes. Careful analysis of the lateral radiograph to determine whether the deformity is secondary to the medial column or true peritalar subluxation may allow superior outcomes. Iatrogenic creation of an excessively rigid medial column may lead to significant instability of the remaining joints in the short term and arthrosis in the long term. Medial column arthrodesis should be used selectively to correct gross instability.

Tarsometatarsal Arthrodesis for Lisfranc Injuries.

This article discusses tarsometatarsal arthrodesis for Lisfranc injuries. Although open reduction and internal fixation has traditionally been the treatment of choice for most Lisfranc fracture-dislocations, there is a trend toward primary fusion, especially for purely ligamentous injuries. Consideration should be made for primary fusion in select fracture-dislocation cases. Primary fusion offers a single-stage alternative with potentially more stable, predictable results overtime.

Stability of Lisfranc injury fixation in Thiel Cadavers: Is routine fixation of the 1st and 3rd tarsometatarsal joint necessary?

BACKGROUND: There is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base) combined with k-wire fixation of the 4th & 5th tarsometatarsal joints is sufficient to stabilise Lisfranc injuries or if fixation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-articular plate which risk causing chondrolysis and/or osteoarthritis. The aims of this cadaveric study were to determine if routine fixation of the 1st and 3rd tarsometatarsal joints is necessary and to determine if a distal to proximal home run screw is adequate. METHODS: Using 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displacement at each ray (1st-5th) and 1st-2nd metatarsal gaping were made during simulated weight bearing with sequential ligamentous injury and stabilisation to determine the contribution of anatomical structures and fixation to stability. RESULTS: At baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st-2nd intermetatarsal gap was 0mm. After transection of the Lisfranc ligament only, there was 1st-2nd intermetatarsal gaping (mean 4.5mm), but no increased dorsal displacement. After additional transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st: 4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased mean dorsal displacement of the 3rd ray to 2.5mm. K-wire fixation of the 3rd ray completely eliminated dorsal displacement. CONCLUSIONS: The results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments (3rd-4th) are intact, the 3rd ray does not need to be routinely stabilised.

Injuries to the Chopart joint complex: a current review.

Chopart complex injuries (CCIs) are thought to be uncommon; however, recent literature states the rate of misdiagnosis to be between 20 and 41%. Chopart complex injuries are not ankle injuries, with which they are initially confused due to a similar mechanism of trauma in many cases. Injury to the Chopart complex commonly affects multiple structures. The key to optimal treatment is a high index of clinical suspicion combined with timely accurate imaging studies. Careful diagnostic workup with high-quality radiographs of the foot in neutral position should be obtained. Computed tomography (CT) and/or magnetic resonance imaging (MRI) are recommended to accurately assess bone and soft tissue injury. CCI frequently leads to prolonged swelling, pain and disability. In some cases, it may result in a posttraumatic flatfoot deformity.