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.

Delayed Treatment of a Medial Swivel Talonavicular Dislocation.

This case describes delayed treatment of a medial talonavicular dislocation with a shear fracture of the talar head, a comminuted posterior talar process fracture, and an intra-articular cuboid fracture with subtle medial displacement of the calcaneocuboid joint and the associated treatment. The injury was sustained in a 35-year-old man following a high-energy motor vehicle accident. Three weeks following the injury, delayed treatment was achieved following an attempted closed reduction under general anesthesia followed by open reduction and percutaneous Kirschner wire fixation. After a 12-month follow-up, the patient was able to return to work and regular activities pain-free without complications. Several associated injuries have been described with isolated talonavicular dislocations. This case reviews the technique and care surrounding this injury pattern and its delayed treatment.

Sports-Related Lisfranc Injuries and Recognition of Lisfranc Variants: Surgical Strategies for Stabilization.

Much has changed since Lisfranc described lesions at the tarsometatarsal (TMT) joint in 1815. What was considered an osseous high-energy condition nowadays is understood as myriad possible presentations, occurring in minor and inconspicuous traumas. Advancements in diagnostics of Lisfranc injury allow recognizing many variants of this trauma presentation, most of them with a focus on ligaments. This perception shifted trends in surgical planning, especially for implants and fixation techniques. These revolutions established a new and evolving universe around TMT lesions, different from what was known only a few years ago and still not enough to completely settle the disease scenario.

Lisfranc injury: A review and simplified treatment algorithm.

BACKGROUND: Lisfranc injuries encompass large spectrum of injuries varying from low energy to high energy complex fracture dislocations. Whilst multiple complex classification systems exist; these do little to aid and direct the clinical management of patients. Therefore, this study aims to provide a simplified treatment algorithm allowing clinicians to standardise care of Lisfranc injuries. METHODS: A comprehensive literature search was performed, and abstracts were reviewed to identify relevant literature. RESULTS: Delay in diagnosis has a negative impact on outcome. If a Lisfranc injury is suspected and plain radiographs are inconclusive; computed tomography and if necessary magnetic resonance imaging are indicated if there is still an index of suspicion. In the absence of joint dislocation/subluxation management will be determined by stability which can be best assessed by weightbearing radiographs. If stable, injuries can be treated conservatively in a non-weight bearing cast for 6 weeks followed by a period of graduated weight bearing. Evidence is mounting that with regard to unstable purely ligamentous Lisfranc injuries primary arthrodesis (PA) has: better functional outcomes, increased cost effectiveness and reduced rates of return to theatre. With regard to bony unstable Lisfranc injuries more research is required before a single treatment modality - PA or open reduction internal fixation can be advocated, due to the lack of randomized control trials and limited patient follow-up periods in existing studies. CONCLUSION: A simplified treatment algorithm excluding the requirement for complex classifications is suggested. This may help with the diagnosis and management of these injuries. It is our believe that this algorithm will aid health professionals to standardize care for these injuries. Further prospective research trials are required to assess outcomes of different modalities of operative management, particularly with regards to open reduction and internal fixation versus primary arthrodesis for bony Lisfranc injuries. LEVEL OF EVIDENCE: Level 5.

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

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

Ultrasound Imaging Guide for Assessment of the Intrinsic Ligaments Stabilizing the Subtalar and Midtarsal Joints.

Ligament injuries around the subtalar, talocalcaneonavicular, and calcaneocuboid joints are often underestimated on clinical and imaging findings during investigation of patients with ankle and foot injuries. Because a delayed diagnosis of midtarsal ligament tears may lead to chronic pain and functional disability, an in-depth knowledge of the complex regional anatomy and of the appropriate ultrasound scanning technique is a prerequisite for evaluating these structures and avoiding misdiagnoses. The objective of this article is twofold: to describe the relevant anatomy and biomechanics related to the ligaments that stabilize the subtalar, talocalcaneonavicular, and calcaneocuboid joints, and to illustrate reasoned landmark-based scanning techniques to provide a systematic examination of these ligaments and thus make ultrasound an effective tool for assessment of patients with suspected subtalar or midtarsal sprain.

Managing Severely Malunited Calcaneal Fractures and Fracture-Dislocations.

Severe calcaneal malunions are debilitating conditions owing to substantial hindfoot deformity with subtalar arthritis and soft tissue imbalance. Type III malunions are best treated with a subtalar distraction bone block fusion. Additional osteotomies may be required for severe varus or superior displacement of the calcaneal tuberosity. Type IV malunions result from malunited calcaneal fracture-dislocations and require a 3-dimensional corrective osteotomy. Type V malunions warrant additional ankle debridement and reconstruction of the calcaneal shape to provide support for the talus in the ankle mortise. Accompanying soft tissue procedures include Achilles tendon lengthening, peroneal tendon release, and rerouting behind the lateral malleolus.

A Novel Technique in Treatment of Calcaneocuboid Dislocation with Bifurcate Ligament Reconstruction Using a Semitendinosus Allograft: A Case Report.

CASE: A 19-year-old woman sustained a plantar flexion-inversion injury to her right ankle after a low-speed motor vehicle collision. Clinical examination demonstrated supinated, adducted deformity of the foot, and prominent calcaneus laterally. Radiographs revealed dislocation of the calcaneocuboid joint, a rare injury, which was successfully stabilized by a novel technique using a hamstring allograft. The presentations and clinical and surgical management of this rare condition are discussed. CONCLUSION: We present a technique that has shown good long-term results in a young patient with recurrent calcaneocuboid joint dislocations. Our novel ligament reconstruction technique using a semitendinosus allograft seems to be a promising treatment option in young patients with unstable calcaneocuboid joints.

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.

Medial Swivel Dislocation of the Talonavicular Joint with Associated Cuboid Fracture.

Medial talonavicular dislocation associated with cuboid fracture is rare. We report an 18-year-old man with this injury who exhibited excellent results after open reduction and stabilization of the joint with temporary Kirshner wires.

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.

OBJECTIVE: The aim of this systematic review was to present the outcome of Lisfranc joint injuries treated with closed reduction and screw percutaneous fixation. METHODS: We 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. RESULTS: Average 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. CONCLUSION: Percutaneous 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 EVIDENCE: Level III, Therapeutic Study.

Flexible Fixation Technique for Lisfranc Injuries.

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

Flexible fixation for ligamentous lisfranc injuries.

Lisfranc injuries require anatomic reduction and stabilization of the tarsometatarsal joints. We describe a novel technique that provides flexible fixation that is simple, cost-effective and that may offer certain advantages over more traditional techniques.

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

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

Comparative anatomy of the mouse and human ankle joint using Micro-CT: Utility of a mouse model to study human ankle sprains.

The use of mouse models as a tool to study ankle sprain requires a basic understanding of the similarities and differences between human and mouse ankle joint anatomy. However, few studies have been conducted that address the merits and drawbacks of these differences in the functioning of joints. Twenty hindfoot specimens were obtained from 10 male C57BL/6J mice and scanned using micro-CT. The foot and ankle skeletal structures were reconstructed in three dimensions. Morphological parameters were then measured using a plane projection method and normalized data were compared with those of human ankles. There was no significant difference in the malleolar width, maximal tibial thickness, tibial arc length, trochlea tali arc length or trochlea tali width of the mouse specimens compared with the human model. However, a groove was observed on the talar dome in the mouse specimens which was not observed in humans, the talar dome being more symmetric. The mouse ankle was to a large extent able to mimic the mechanism of a human ankle and so a mouse model could be appropriate for expanding our understanding of ankle biomechanics in general. However, the structural differences in the talar dome in the mouse and human should not be ignored. Although there are some differences in the mouse and human ankle that cannot be ignored, compared to other animals, the human ankle is more similar to that of the mouse.