Surgical controversies and current concepts in Lisfranc injuries.

INTRODUCTION: Lisfranc injuries, not as rare as previously reported, range from ligamentous to complex fracture-dislocations. Anatomical studies have identified a complex of discrete structures, and defined the anatomical characteristics of the Lisfranc joint. SOURCES OF DATA: A narrative evidence-based review encompassed and analyzed published systematic reviews. Outcomes included clinical and surgical decision-making, including clinical-presentation, diagnosis, pathological-assessment, surgical-management techniques and indications, post-surgical care and comparative outcomes. AREAS OF AGREEMENT: Better understanding of the Lisfranc complex anatomy aids surgical treatment and tactics. Prognosis is related to injury severity, estimated by the number of foot columns affected. Surgical outcome is determined by anatomical reduction for most fixation and fusion techniques. Appropriate treatment allows return to sport, improving outcome scores. AREAS OF CONTROVERSY: Identification of Lisfranc injuries may be improved by imaging modalities such as weight-bearing computer tomography. Recent evidence supports dorsal plate fixation as a result of better quality of reduction. In complex injuries, the use of combined techniques such as trans-articular screw and plate fixation has been associated with poorer outcomes, and fusion may instead offer greater benefits. GROWING POINTS: Open reduction is mandatory if closed reduction fails, highlighting the importance of understanding surgical anatomy. If anatomical reduction is achieved, acute arthrodesis is a safe alternative to open reduction internal fixation in selected patients, as demonstrated by comparable outcomes in subgroup analysis. AREAS FOR DEVELOPING RESEARCH: The current controversies in surgical treatment remain around techniques and outcomes, as randomized controlled trials are infrequent.

Treatment of Lisfranc Injuries Using Interosseous Suture Button: A Retrospective Review of 84 Cases With a Minimum 3-Year Follow-Up.

Lisfranc fracture dislocation is an injury often encountered by the foot and ankle surgeon. This injury, depending on the severity and level of energy, has been shown to lead to posttraumatic osteoarthritis and chronic pain if undiagnosed or improperly managed. The purpose of this study was to retrospectively evaluate the surgical repair with the use of an interosseous suture button for Lisfranc injuries with isolated ligamentous disruption. From 2008 through 2016, 104 patients were consecutively enrolled who underwent open reduction internal fixation (ORIF) of the Lisfranc complex with a suture button and stabilization of the medial and intermediate cuneiform with a 4.0-mm screw. Eighty-four patients were available for a 3-year minimum follow-up. The mean return to full weightbearing was 11 days protected in a controlled ankle motion (CAM) boot. American Orthopedic Foot & Ankle Society (AOFAS) and visual analog scale (VAS) scores improved from 30 and 8.4, respectfully, preoperatively to 90 and 1.3 postoperatively. The mean preoperative step-off between the second metatarsal base and intermediate cuneiform was found to be 3.15 mm. The immediate postreduction weightbearing radiograph measured 0.25 mm and 0.43 mm at the final follow-up evaluation, a difference that was found to be significant. There were no revision arthrodeses performed and no removal of the suture button during this time period. ORIF using an interosseous suture button appears to have an adequate medium-term patient satisfaction; however, there is evidence of minimal diastasis in some patients at 3 years postoperatively in ligamentous Lisfranc fracture dislocations.

Multiple Tarsometatarsal Coalitions: A Case Report.

Tarsometatarsal coalitions have rarely been reported in published literature. The few reported cases presented with varying degrees of pain. Here, we describe the case of a 16-year-old female with multiple tarsometatarsal coalitions, the first of its kind in the reported literature. Descriptions in anthropology literature suggest that these lesions might be more common than previously thought and, in some circumstances, can become symptomatic enough to warrant intervention.

Impact of the Subtle Lisfranc Injury on Foot Structure and Function.

BACKGROUND: The subtle Lisfranc injury is the disruption of the osteoligamentary complex between the first cuneiform and the second metatarsal, resulting in minor widening of this space that is often difficult to detect with plain radiographs. In this study, we assessed the results after treatment of the different stages of subtle Lisfranc injuries, focusing on their impact on foot arch anatomy and functionality at short- to midterm follow-up. METHODS: A retrospective study including patients treated in our center for a subtle Lisfranc injury between 2012 and 2019 was conducted. Demographic, epidemiologic, radiographic, and clinical data were obtained and assessed, focusing on foot arch structure and foot function, which was evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot score and the Foot Function Index (FFI). RESULTS: A total of 42 patients with a mean age of 49 ± 17.5 years were included, with an average of 4.3 years' follow-up (range, 1-8). Stage I injuries according to Nunley classification represented 19% and were treated conservatively. Stage II (66.7%) and stage III (14.3%) injuries were treated operatively, via osteosynthesis with screws (74%), K-wires (19%), or plates (7%). Flattening of foot arch after treatment was observed in 42.9% of patients, with significant increases in Costa-Bertani (12 ± 7 degrees), Hibbs (7 ± 6 degrees), and Meary (3 ± 1 degrees) angles. Other complications included complex regional pain syndrome (28.6%) and painful hardware (23.8%). Secondary joint arthrodesis was needed in 16.6% of patients. Chronic pain was present in 71.4% of patients with a mean visual analog scale (VAS) pain score at final follow-up of 4 of 10 points. Results in AOFAS midfoot score and FFI were 87.4 ± 8.3 and 15 ± 6.4, respectively. CONCLUSION: The subtle Lisfranc injury shows dissociation between the initial relatively mild radiographic changes and important future complications. Chronic pain and foot arch flattening were not uncommon. Overall foot function in the short- or midterm was found to be modestly diminished in this somewhat heterogenous cohort. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Return to Play After Low-Energy Lisfranc Injuries in High-Demand Individuals: A Systematic Review and Meta-Analysis of Athletes and Active Military Personnel.

BACKGROUND: Although studies are available on high-energy Lisfranc injuries, the evidence for increasingly reported low-energy Lisfranc injuries in active individuals, including athletes and military personnel, remains scarce and mostly retrospective. PURPOSE: This meta-analysis aimed to review the return-to-play (RTP) and return-to-duty (RTD) rates with regard to the anatomic type and the management of low-energy Lisfranc injuries in a high-demand, active population. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched the MEDLINE (PubMed), EMBASE, Google Scholar, and Cochrane databases through June 2019 to identify studies on low-energy Lisfranc injuries in athletes and military personnel. The primary outcomes were RTP/RTD rates and time to RTP/RTD, and the secondary outcomes were time missed from practice, games missed, time to full recovery, midfoot arthritis rate, and reoperation rate. RESULTS: Overall, 15 studies (N = 441 patients) were included in the meta-analysis. Of these, 6 studies were of level 3 evidence, 8 studies were level 4 (case series), and 1 study was level 5. Of the 441 subjects, 380 (86.17%) were able to RTP and RTD. There was no statistically significant difference in RTP rates for operative versus nonoperative treatment, ORIF versus PA, or bony versus ligamentous injuries. The mean time missed from practice/duty for operative versus nonoperative treatment was 58.02 days (95% CI, 13.6-102.4 days; I 2 = 98.03%) and 116.4 days (95% CI, 62.4-170.4 days; I 2 = 99.45%), respectively. The mean time missed from practice/duty for bony versus ligamentous injury was 98.9 days (95% CI, 6.1-191.7 days; I 2 = 99.82%) and 76.5 days (95% CI, 37.9-115.02 days; I 2 = 99.83%), respectively, with no statistically significant differences (standardized mean difference = 3.62 days [95% CI: -5.7 to 13 days]; I 2 = 83.17%). CONCLUSION: This review indicated an overall excellent RTP/RTD rate for low-energy Lisfranc injuries in high-demand individuals. The time missed from athletic participation/military duty was not affected by injury treatment type, the bony versus ligamentous nature of the injury, or athlete player position. However, the low evidence levels and significant heterogeneity of the included studies precludes making conclusions regarding length of time missed or optimal management. Higher-quality studies on low-energy Lisfranc injuries are needed.

Lisfranc Injury: Current Concepts.

Lisfranc injuries range from sprain to fracture-dislocation. Radiologists must have a thorough understanding of anatomy, mechanisms, and patterns of these injuries to diagnose and help clinicians assess treatment options and prognosis. The initial imaging evaluation of patients with a suspected Lisfranc injury consists of non-weight-bearing radiographs. In patients with high-energy injuries, the diagnosis is straightforward, and patients usually undergo CT for surgical planning. In patients with low-energy injuries, when findings on initial radiographs are equivocal, further evaluation is performed with weight-bearing radiographs, CT, or MR imaging. Stable injuries are treated conservatively, whereas all other injuries require surgical interventions.

Nonweightbearing Radiographs in Patients With a Subtle Lisfranc Injury.

BACKGROUND: A midfoot sprain can be easily missed because of minimal findings on initial radiographs, which are almost universally nonweightbearing. We investigated preoperative nonweightbearing plain radiographic images in patients who were found to have unstable subtle Lisfranc injuries. METHODS: We retrospectively reviewed 51 patients who were operated on between February 2004 and March 2015. Abnormal preoperative radiographic findings and intraoperative instability were compared. The relationship was calculated with Fisher's exact test. RESULTS: Based on intraoperative findings, medial cuneiform (C1)-second metatarsal (M2) instability was observed in 50 cases (98%), which was the most common. Thirty-nine cases (76.4 %) had multiple joint (at least 2) instability. In the preoperative radiologic findings, C1-M2 diastasis was the most common abnormal finding, in 46 cases (90.1%). Specificity and positive predictive value were 1.0 in C1-M2 avulsion, diastasis, and C1-intermediate cuneiform (C2) diastasis. Abnormal findings of C1-C2, C1-M1, and C2-M2 showed a significant relationship with intraoperative instability ( P < .05). CONCLUSION: C1-M2 avulsion and diastasis and C1-C2 diastasis were definite preoperative predictors of instability. In unstable subtle Lisfranc injuries, 90% had at least a minor radiographic abnormality at the C1-M2 joint on nonweightbearing radiographs. However, caution should be exercised to identify instability without radiographic abnormality in the C1-M2 joint. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Sports health magnetic resonance imaging challenge.

Injuries to the Lisfranc ligament complex are often suspected, particularly in the setting of midfoot pain without radiographic abnormality. Knowledge of the anatomy and magnetic resonance imaging findings of injuries to this region is helpful for the diagnosing and treating physicians.