Treatment of Lisfranc Joint Injury: Current Concepts

Review Article Treatment of Lisfranc Joint Injury: Current Concepts

Abstract Troy S. Watson, MD Injuries to the tarsometatarsal joint complex, also known as the Paul S. Shurnas, MD Lisfranc joint, are relatively uncommon. However, the importance of an accurate diagnosis cannot be overstated. These injuries, Jacques Denker especially when missed, may result in considerable long-term disability as the result of posttraumatic arthritis. A high level of suspicion, recognition of the clinical signs of injury, and appropriate radiographic studies are needed for correct diagnosis. When surgery is indicated, closed reduction with percutaneous screw fixation should be attempted. If reduction is questionable, open reduction should be performed. Screw fixation remains the traditional fixation technique.

he Lisfranc joint, also referred proximately one third of all Lisfranc Tto as the tarsometatarsal (TMT) injuries,5 with the remainder typically joint complex, is named for Jacques the result of high-energy forces sus- Lisfranc (1790-1847), a French sur- tained in motor vehicle accidents, in- geon who served in Napoleon’s dustrial accidents, and falls from a army. Lisfranc described an amputa- height.7 Midfoot injuries sustained dur- tion involving the TMT joint second- ing athletic activity constitute a signif- ary to a vascular injury incurred icant number of low-energy injuries, oc- From the Desert Orthopaedic Center, Las Vegas, NV when a soldier fell from a horse with curring in up to 4% of American 8,9 (Dr. Watson), the Columbia his foot caught in the stirrup.1,2 Lis- football players per season. A high Orthopaedic Group, Columbia, MO franc injury has commonly been used index of suspicion is needed to accu- (Dr. Shurnas), and the Department rately diagnose TMT joint injury and of Surgery, Touro University School to describe injuries to the bases of of Medicine, Henderson, NV the five metatarsals (MTs), their ar- attempt to avoid the late sequelae of (Mr. Denker). ticulations with the four distal tarsal posttraumatic arthritis. Dr. Watson or an immediate family bones, and the Lisfranc ligament, a member serves as a paid consultant strong interosseous attachment lo- Anatomy to or is an employee of Arthrex. cated between the medial cuneiform Dr. Shurnas or an immediate family member serves as a paid consultant and the second MT. The Lisfranc complex is made up of to or is an employee of Arthrex. Injuries to the TMT joint complex bony and ligamentous elements that Neither Mr. Denker nor any occur in 1 per 55,000 persons each combine to add structural support to immediate family member has received anything of value from or year in the United States, accounting the transverse arch. The bony archi- owns stock in a commercial for approximately 0.2% of all frac- tecture is composed of nine bones— company or institution related tures.3 Nearly 20% of these injuries five MTs and their respective articu- directly or indirectly to the subject of are misdiagnosed or missed on initial lations with the cuneiforms medially this article. radiographic assessment.4 More Lis- and the cuboid laterally. The TMT J Am Acad Orthop Surg 2010;18: franc injuries are being diagnosed to- joint complex represents the dividing 718-728 day, likely because of improvements line between the midfoot and the Copyright 2010 by the American in CT and MRI.5,6 forefoot.10 Academy of Orthopaedic Surgeons. Low-energy trauma accounts for ap- Several osseous relationships con-

718 Journal of the American Academy of Orthopaedic Surgeons Troy S. Watson, MD, et al

Figure 1 Figure 2

Anatomic location of the dorsal, Lisfranc, and plantar ligaments. (Redrawn with permission from Solan MC, Moorman CT III, Miyamoto RG, Jasper LE, Belkoff SM: Ligamentous restraints of the A, The plantar aspect of the midfoot, including the plantar bundle of the second tarsometatarsal joint: A Lisfranc ligament (pC1-M2M3), the first tarsometatarsal ligament (pC1-M1), biomechanical evaluation. Foot and the second tarsometatarsal ligament (pC2-M2). B, The dorsal aspect of Ankle Int 2001;22:637-641.) the midfoot, including the dorsal bundle of the Lisfranc ligament (dC1-M2) and the medial-middle cuneiform ligament (dC1-C2). C1 = medial cuneiform, C2 = middle cuneiform, C3 = lateral cuneiform, M1 = first metatarsal, M2 = second metatarsal, M3 = third metatarsal. (Adapted with permission ous, and plantar—which maintain from Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC: the crucial mortise osseous relation- Prediction of midfoot instability in the subtle Lisfranc injury: Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg ship. The oblique interosseous liga- Am 2009;91:892-899.) ment, also referred to as the Lisfranc ligament, is the strongest structure supporting the TMT joint complex.16 tribute to the intrinsic stability of the lower medial mortise depth com- The ligament is 8 to 10 mm wide TMT joint. The trapezoidal shape of pared with control subjects. They and 5 to 6 mm thick, and it is mir- the middle three MT bases and their suggested that adequate mortise rored superiorly and inferiorly by a associated cuneiforms produce a sta- depth provides for greater stability dorsal and plantar oblique ligament10 ble arch referred to as the “trans- by allowing for a stronger Lisfranc (Figure 2). The plantar ligament that verse” or “Roman” arch.11,12 The ligament. runs parallel to the Lisfranc ligament keystone to the transverse arch is the de Palma et al10 organized the sup- originates on the inferolateral aspect second TMT joint, a product of the porting ligamentous array into of the medial cuneiform and divides recessed middle cuneiform, which groups defined by their course (ie, into two bands: the deep band, occupies a position 8 mm proximal longitudinal, oblique, transverse) which inserts into the second MT, to the medial cuneiform and 4 mm and location (ie, dorsal, interosseous, and the superficial band, which in- proximal to the lateral cuneiform.13 plantar). The transverse ligaments at- serts into the third MT.13 This allows five stabilizing structures tach the second through fifth MT In a biomechanical evaluation, So- to articulate with the recessed second bases; there are no such ligaments lan et al16 assessed the strength of MT, thereby enhancing the stability between the first and second MT each ligamentous set—dorsal, in- of the TMT joint complex. Anatomic bases10,15 (Figure 1). However, situ- terosseous, and plantar—by stressing variances frequently predispose to ated between the medial cuneiform it to failure. They concluded that the injury. Peicha et al14 showed that per- and second MT base are three Lisfranc ligament was strongest, fol- sons with Lisfranc injury had a shal- oblique ligaments—dorsal, interosse- lowed by the plantar ligaments and

December 2010, Vol 18, No 12 719 Treatment of Lisfranc Joint Injury: Current Concepts the dorsal ligaments. These results American football players when they TMT injuries, prognosis depended confirmed the observations of de are lying prone on the ground and more on joint incongruity than on Palma et al10 and Sarrafian.13 Thus, another player falls on the prone ath- mechanism of injury. ligamentous disruption typically be- lete’s heel. External rotation on a In 1986, Myerson et al7 proposed a gins with the weaker dorsal liga- pronated forefoot is responsible for a scheme based on these previous sys- ments, followed by the plantar liga- substantially unstable Lisfranc liga- tems to aid in clinical decision mak- ments, and, finally, the Lisfranc mentous injury.7,20 The injuries can ing. They classified injuries as fol- ligament.17 Structural stability to the be largely secondary to an abduction lows: type A, total incongruity of the transverse arch is enhanced by the stress to the midfoot. This injury pat- TMT joint; type B1, partial incon- short plantar muscles as well as by tern is best seen in sports that require gruity affecting the first ray in relative isolation (ie, partial medial the muscular and tendinous support use of a stirrup, such as equestrian incongruity); type B2, partial incon- of the peroneus longus and the tibia- events and windsurfing. In cases such gruity in which the displacement af- lis anterior and tibialis posterior. as these, the forefoot is abducted fects one or more of the lateral four around a fixed hindfoot, causing dis- MTs (ie, partial lateral incongruity); location of the second MT and lat- and type C1 and C2, a divergent pat- Mechanism of Injury eral displacement of the remaining tern, with partial or total displace- MTs. Most injuries to the TMT complex ment7 (Figure 3). These same authors Direct injuries are usually associ- can be designated as indirect or di- coined the phrase tarsometatarsal ated with a crush injury. Depending rect. Indirect injuries can be high en- joint complex in favor of older desig- on the location of force applied to ergy, as in motor vehicle accidents nations such as Lisfranc or TMT in- the TMT joint complex, the MTs can and falls from a height, or caused by juries because the former describes undergo plantar or dorsal displace- low-energy forces, such as those in- all bones and joints involved in TMT ment.7 These fracture-dislocations curred during athletic activity.3 Most fracture-dislocation, including the in- are often associated with significant commonly, indirect injuries are asso- tercuneiform and naviculocuneiform soft-tissue trauma, vascular com- ciated with a longitudinal force ap- joints.7 promise, and compartment syn- plied to the forefoot, which is then In 2001, Chiodo and Myerson23 drome.15,21 subjected to rotation and compres- presented a columnar classification sion.18 Excessive plantar flexion and of TMT joint injury based on the abduction forces are the most com- Classiﬁcation three mechanical columns of the foot mon individual indirect mechanisms to aid in treatment planning. The leading to midfoot disruption. As the Several classification systems have first TMT and medial naviculocunei- second MT dislocates or fractures, been developed and updated in the form joints make up the medial col- the MTs move laterally.19 past century, with the authors dis- umn. The middle column includes Two different plantar flexion playing a tendency toward using the articulations between the second mechanisms lead to dorsal joint fail- joint incongruity rather than mech- and third TMT joints and those be- ure. The first occurs in ankle equinus anism of injury as a basis for treat- tween the middle and lateral cunei- and metatarsophalangeal joint plan- ment and prognosis.2 These classifi- form with the navicular bone. The tar flexion, with the Lisfranc joint cation systems are inherently lateral column consists of articula- engaged along an elongated lever effective in standardizing terminol- tions between the cuboid and the arm.2 The joint is “rolled over” by ogy and allowing for the description fourth and fifth MTs. Midfoot mo- the body; this commonly occurs of both high- and low-impact inju- tion is highlighted in this system, when a person misses a step or unex- ries; however, they may fall short in with strong prognostic implications. pectedly catches the heel or latter determining management and pre- Komenda et al11 reported that post- half of the foot on the curb as he or dicting clinical outcome. traumatic arthritis is more common she is stepping down.8 Dorsal dis- In 1909, Quenu and Kuss22 first at the base of the second MT, sug- placement caused by plantar flexion described injuries to the TMT joint gesting that incongruity is better tol- can also occur when a force is ap- based on the direction of MT dis- erated at the medial and lateral col- plied along the long axis of the foot placement. Several modifications fol- umns. The lateral column, which has with the foot plantarflexed and the lowed, with the most comprehensive the greatest amount of sagittal plane knee anchored on the ground.18 This being described by Hardcastle et al2 motion, is the least likely to be in- is a common mechanism seen in in 1982. In their experience with volved in posttraumatic arthritis.

720 Journal of the American Academy of Orthopaedic Surgeons Troy S. Watson, MD, et al

Figure 3

Classification of tarsometatarsal joint injury. The shaded areas represent the injured or displaced portion of the foot. A, Type A, total incongruity, which involves displacement of all five metatarsals (MTs) with or without fracture at the base of the second MT. The usual displacement is lateral or dorsolateral, and the MTs move as a unit. These injuries are “homolateral.” B, In type B injuries, one or more articulations remain intact. Type B1 represents partial incongruity with medial dislocation. Type B2 represents partial incongruity with lateral dislocation; the first MT cuneiform joint may be involved. C, Type C injuries are divergent, with either partial (C1) or total (C2) displacement. The arrows in C2 represent the forces through the foot leading to a divergent pattern. (Redrawn with permission from Myerson MS, Fisher RT, Burgess AR, Kenzora JE: Fracture-dislocations of the tarsometatarsal joints: End results correlated with pathology and treatment. Foot Ankle 1986;6:225-242.)

One shortcoming of traditional creased uptake on bone scan, with classification systems is the lack of negative radiographic findings. Stage Diagnosis emphasis on the simple diastasis seen II injuries exhibited diastasis between in low-energy athletic injuries. This the first and second MTs of 1 to 5 Lisfranc joint injuries can be difficult type of injury may involve the inter- mm greater than that of the the con- to accurately diagnose because gross cuneiform space or the naviculocune- tralateral side, without loss of mid- lateral deviation or subluxation of iform joints. In 2002, Nunley and foot arch height. Diastasis >5 mm the forefoot is less common than Vertullo24 classified athletic midfoot and loss of midfoot arch height signi- subtle midfoot injury. Patients often injuries into three groups based on fied stage III injury. Nonsurgical present with inability to bear weight clinical findings, weight-bearing ra- treatment of stage I patients and sur- and with swelling in the midfoot re- diographs, and bone scintigraphy. gical treatment of stage II and III pa- gion. Examination of the foot reveals Athletes with stage I injury had pain tients led to an excellent result in forefoot and midfoot edema as well only at the Lisfranc complex and in- 93%. as plantar arch ecchymosis (ie, plan-

December 2010, Vol 18, No 12 721 Treatment of Lisfranc Joint Injury: Current Concepts

Figure 4 sprain or instability include tender- demonstrate instability when initial ness to palpation along the TMT radiographs are normal.29 However, joints4 and the inability to bear this may require an ankle block or weight while standing on the tip- general anesthesia because of the toes.3 A stress test may be per- presence of pain; thus, it is rarely formed. The clinician grasps the first performed. and second MTs and moves them in AP radiographs are used to demon- plantar flexion and dorsiflexion (ie, strate malalignment of the first and piano key test) as well as abduction second TMT joints, whereas incon- and adduction, noting any discom- gruity at the third and fourth joints are better visualized on a 30° oblique fort or subluxation in the midfoot. view.28 On the lateral view, the dorsal The first and second MTs should and plantar aspects of the MTs also be stressed divergently. Com- should correspond with the cunei- partment syndrome should be ruled form and cuboid. A tangential line out in patients who present with se- Schematic representation drawn through the medial aspect of demonstrating the method of vere traumatic midfoot injuries that evaluating the integrity of the the medial cuneiform and navicular are accompanied by significant 30 midfoot arch on weight-bearing should intersect the first MT base. lateral radiographs. A, Normal swelling and pain. The dorsalis pedis Lateral weight-bearing radiographs relationship demonstrating the pulse should be evaluated because can be used to identify flattening of position of the ﬁfth metatarsal blood flow may be compromised sec- 31 plantar to the medial cuneiform (a the longitudinal arch as well as dor- positive value). B, Flattening of the ondary to severe dislocation of the sal displacement at the second TMT 27 midfoot arch positions the medial second MT. joint (Figure 4). cuneiform plantar to the ﬁfth Radiographic studies are done to metatarsal (a negative value). Radiographic Imaging (Adapted with permission from determine whether an injury is stable Faciszewski T, Burks RT, Manaster Lisfranc injuries are a challenge to or unstable. The AP radiograph BJ: Subtle injuries of the Lisfranc diagnose; approximately 20% of in- should show alignment of the medial joint. J Bone Joint Surg Am juries go unrecognized,28 likely sec- 1990;72:1519-1522.) border of the second MT and the ondary to the difficulty encountered medial border of the middle cunei- with standard radiographic imaging. form. The oblique view should show Many so-called sprains present with alignment of the medial border of tar ecchymosis sign), which is con- non–weight-bearing radiographs that the fourth MT and the medial border sidered to be nearly pathognomonic are difficult to interpret. In a recent of the cuboid. Close examination of for Lisfranc complex injury.25 When study, Nunley and Vertullo24 found these lines for displacement will help a diastasis is noted between the hal- that 50% of athletes with midfoot the clinician with subtle cases. lux and second toe, the patient is injuries had normal non–weight- Diastasis between the first MT–me- said to have a positive gap sign.26 bearing radiographs. dial cuneiform and second MT of 2 Lisfranc injury should be suspected Initial imaging of a suspected Lis- mm greater than on the contralateral when a patient reports a consistent franc injury should include routine side, or TMT joint subluxation of 2 mechanism of injury and presents AP, lateral, and oblique views of the mm greater than on the contralateral with midfoot pain and swelling. foot, with the image taken parallel to side, indicates instability and is an When Lisfranc injury is suspected, the midfoot joints. To aid in the di- indication for surgical intervention29 it is important to accurately diagnose agnosis of more subtle injuries, a (Figure 5). Diastasis between the first whether the injury is a sprain or rep- weight-bearing film with both feet and second MT in the injured mid- resents an unstable columnar injury on a single cassette is obtained. This foot is considered normal provided resulting from complete ligamentous last view serves as a stress view of that it measures <2.7 mm.31 Avulsion disruption. The passive pronation- the foot. It is helpful to explain this of the second MT base or medial cu- abduction test described by Curtis to the patient before obtaining the neiform produces a fleck sign, as de- et al8 is performed by eliciting pain film so that compliance with evenly scribed by Myerson et al.7 The AP on abduction and pronation of the distributed weight bearing can be ob- and oblique radiographs should be forefoot with the hindfoot fixed. tained. An AP abduction-pronation investigated for this finding. The Other signs suggestive of midfoot stress view is occasionally used to most common abnormality in Lis-

722 Journal of the American Academy of Orthopaedic Surgeons Troy S. Watson, MD, et al franc injuries is the lateral step-off at Figure 5 the second TMT joint.

Additional Imaging Additional studies may be helpful, including bone scans, MRI, and CT. Bone scans are typically reserved for patients with a midfoot injury but with negative radiographic findings.24 When plain radiographs and the physical examination are equivo- cal, MRI can be used to provide excellent depiction of the soft tissues.6,32 Additionally, in the high- level athlete, MRI may provide information to help the treating phy- sician make a determination on return-to-play status. In a recent study evaluating the predictive value of MRI for midfoot instability, Rai- kin et al6 found that MRI demon- A, AP weight-bearing radiograph following injury to the midfoot in a 45-year- strating a rupture or grade 2 sprain old woman. Note the displacement of the second metatarsal (MT) base laterally and the fleck sign between the first and second MT bases. This is a of the plantar ligament between the type B2 fracture. B, AP weight-bearing radiograph following open reduction first cuneiform and the bases of the and internal fixation. C, AP weight-bearing radiograph following hardware second and third MTs is highly pre- removal. Note the reduction of the second MT into the keystone. dictive of midfoot instability, and these patients should be treated with Other factors, such as energy of the feel that, when possible, a diagnosis surgical stabilization. CT is recom- injury, cartilage damage, and soft- should be made without subjecting a mended in patients presenting with tissue injuries, can compromise the patient to anesthesia. The last resort, high-energy injuries in which im- final outcome. Most of the literature stress examination under anesthesia, proved detection and delineation of supports that anatomic alignment is is rarely required. Patient consent fractures is required. However, sub- necessary, and good or excellent re- tle displacement may not be demon- should be obtained for possible open sults have been achieved in 50% to strated because this is a non–weight- reduction and internal fixation 95% of patients with anatomic bearing study. These images may (ORIF) if a stress examination is alignment, compared with 17% to demonstrate comminution and intra- deemed to be necessary. 30% of patients with nonanatomic articular extension or interposed soft The patient with minimal ambula- alignment.2,7,27,34 tissues not appreciated on the initial tory ability, an insensate foot, or pre- radiographic assessment.33 existing inflammatory arthritis may Nonsurgical be best treated nonsurgically. Recon- Any measurable disturbance in nor- struction with midfoot arthrodesis Management mal radiographic anatomy may be can be performed later if pain per- an indication of instability and the sists. The authors prefer to use a The key to successful management is need for surgical consideration. The CAM walking boot for 6 to 10 the determination whether to use key to selecting a nonsurgical option weeks in patients with stable injuries surgical stabilization. Regardless of lies in ensuring that surgical inter- that can be managed nonsurgically. the severity of injury, the goal of vention is not necessary. Table 1 lists Weight bearing is allowed as toler- treatment is a painless, plantigrade, five steps that can be used to deter- ated, and follow-up weight-bearing stable foot. Maintenance of ana- mine whether a patient requires sur- radiographs are obtained 2 weeks af- tomic alignment seems to be the crit- gical treatment. Evaluation of subtle ter injury to ensure there are no ical factor in achieving a satisfactory Lisfranc injury is time-consuming changes in alignment. Subsequently, result, but it does not guarantee it. and potentially expensive, but we a brief 3- to 6-week course of physi-

December 2010, Vol 18, No 12 723 Treatment of Lisfranc Joint Injury: Current Concepts

Table 1 Stepwise Evaluation of a Patient With Lisfranc Injury to Determine Whether to Perform Nonsurgical or Surgical Treatment Step Study Result Recommendation Rationale

1 Physical examination Plantar bruising, painful Obtain weight-bearing radio- Weight-bearing radiographs are piano key test, midfoot graphs unless injury is obvi- always useful, but oblique views swelling ous with non–weight- may be helpful for the tentative bearing images patient 2 Radiography Loss of arch on compara- ORIF is indicated with posi- Any measurable subluxation is an tive weight-bearing lateral tive results. External rota- indication for ORIF. When in radiograph, widening be- tion views are necessary doubt, proceed with further tests. tween the first and second when there is uncertainty On MRI, edema indicates midfoot metatarsal bases on com- based on plain radiographs injury, and subluxation confirms parative AP views, fleck or the patient cannot bear Lisfranc injury. sign weight. When uncertainty remains, MRI is useful. 3 MRI Edema at the tarsometatar- If edema but no ligament tear MRI is more sensitive to edema in sal joint, bone bruise, sub- or subluxation, then CT is subtle injuries. CT may better luxation, or ligament tear recommended. Perform illustrate subluxation, but MRI ORIF in the presence of may show both. subluxation or a clear ligament tear. 4 CT 1 mm of subluxation Strong evidence for Lisfranc MRI with edema and no ligament injury when edema is noted tear combined with normal CT on MRI and subluxation on requires stress examination under CT. ORIF is indicated. anesthesia, with possible ORIF 5 Stress examination Subluxation ORIF When negative, treat as a sprain

ORIF = open reduction and internal ﬁxation cal therapy to work on gait training jury, as there are often distracting in- primary factors for our preference and balance is often helpful. We have juries that may delay the diagnosis. for ORIF. The midfoot TMT joints found it of help to transition these The timing of surgery is predicated have poor tolerance to mild mal- patients into a comfort supportive on resolution of swelling, when the alignment35 as joint contact area is shoe with a full-length total contact skin begins to wrinkle. In more se- reduced, predisposing to arthritis. orthosis. It typically takes approxi- vere injuries, 3 weeks of bulky Jones Moreover, closed reduction may be mately 4 months for these patients to splinting and elevation is required blocked or inhibited by bone frag- recover from a nonsurgical Lisfranc before it is safe to perform surgery. ments or soft tissue, and the accu- injury; patients should be informed Commercially available ice therapy racy of assessing 1 to 2 mm of sub- of this time frame at the onset of units can be placed over the splint luxation radiographically is limited. treatment. and may help expedite local pain re- Some authors believe closed reduc- lief and reduction in swelling, before tion under fluoroscopic guidance Surgical and after surgery. Ideally, Lisfranc in- should be attempted first because Unstable injuries, even subtle ones, juries are best managed within the percutaneous screw fixation has are managed surgically. Subtle Lis- first 2 weeks following the inciting been used successfully in the past.19 franc injuries are occurring with in- event, but we have treated many in- Dorsal incisions centered over the creasing frequency, likely because of juries up to 6 weeks posttrauma with involved joints are used to approach greater participation in high-demand successful anatomic reduction and the midfoot; small bone fragments sports. Obvious injuries in multiple outcome. are excised, and larger pieces may be trauma patients are not often missed, ORIF is our preferred technique fixed.7,12,27,34 Many forms of fixation but more subtle injuries are a com- for subtle and obvious injuries. The are available depending on the na- mon source of continued disability. presence of osteochondral fragments, ture of the injury and surgeon prefer- Careful examination of the trauma soft-tissue interposition, and clear vi- ence. patient is required with any foot in- sualization of the reduction are the For more obvious Lisfranc

724 Journal of the American Academy of Orthopaedic Surgeons Troy S. Watson, MD, et al fracture-dislocation, screw fixation Figure 6 has been shown to have lower rates of redisplacement7,27,34 and faster return to weight bearing27,34 postoperatively compared with Kirschner wire (K-wire) fixation. Small-fragment (3.5 mm) cortical screw fixation is recommended for the first, second, and third TMT joints. The fourth and fifth joints may be pinned with K-wires. K-wire fixation is usually removed at 6 weeks postoperatively, whereas screws are left in place for 4 months. A short leg non–weight- bearing cast is used for the first 3 weeks, and a CAM boot is used for the next 3 to 5 weeks, progressing to full weight bearing by 8 weeks postoperatively. Patients are usually allowed to return to a shoe with an orthosis at 3 months after surgery, and screws are typically removed 4 months postoperatively. A, AP weight-bearing radiograph demonstrating Lisfranc injury with a Progressive physical therapy, which comminuted fracture at the second metatarsal base with joint impaction (type usually is initiated after full weight B2). The first, second, and third joints were involved at the time of surgery. B, AP radiograph following open reduction and internal fixation using a one- bearing has begun, is used for bal- third tubular plate demonstrating screw fixation and bridge plating of the ance, gait training, and edema con- second joint with good reduction. trol. Once the percutaneous incisions have healed following screw removal, physical therapy is recom- between groups treated with ORIF fractures with bony fragments in the 37 menced for 4 to 6 weeks, if neces- versus primary arthrodesis. How- TMT joints (Figure 6) and total liga- sary. Primary arthrodesis may be ever, the reoperation rate was signifi- mentous injuries (Figure 7), and as indicated in cases of severe cartilage cantly lower in the fusion group than an alternative surgical treatment in damage, preexisting midfoot arthri- in the ORIF group, in whom routine certain cases, such as joint damage tis, and delayed diagnosis as well as removal of hardware was performed and loss of fixation. We use dorsal in select patients with neuropathic (17% versus 79%, P < 0.05). Addi- plating in approximately 10% of pa- injuries. Primary arthrodesis has tional prospective studies are needed tients with comminuted joint inju- been shown to be a reliable method to define what subset of patients will ries. The concern for joint damage of surgical treatment.19 benefit from primary arthrodesis be- resulting from screw fixation across In a randomized prospective study, fore making this the definitive rec- the TMT joints is eliminated. Al- Ly and Coetzee36 compared ORIF ommended treatment. though K-wire fixation minimizes with primary arthrodesis in patients the articular damage, redisplacement with a primary ligamentous injury. Future Techniques in rates are unacceptably high. More- They found that patients treated Surgical Management over, given the potentially slow heal- with primary arthrodesis had a Concerns exist regarding the poten- ing rate of pure ligamentous inju- quicker recovery, a higher foot func- tial damage that may be caused by ries,38 plating provides prolonged tion index score, and a superior re- traditional screw placement across fixation. Wound problems are not turn to function than did those who the TMT joints, possibly resulting in more common with plating than underwent ORIF. In a recent pro- the late development of posttrau- with wire fixation. The postopera- spective study evaluating all types of matic arthritis and a poor outcome. tive regimen is the same, although Lisfranc complex injuries, no differ- We consider using dorsal plating for the surgeon can elect to leave the ence was seen in functional outcome bridging fixation of comminuted plate in place. Hand plating sets are

December 2010, Vol 18, No 12 725 Treatment of Lisfranc Joint Injury: Current Concepts

Figure 7 tous injuries take far longer to heal than do their bony counterparts,38 and a novel approach to these difficult cases may improve outcomes with a more rapid return to sports. The authors may use Mini Tightrope (Arthrex, Naples, FL) or EndoButton (Smith & Nephew Endoscopy, An- dover, MA) fixation. The EndoBut- ton is placed across the base of the second MT into the medial cuneiform, mimicking the Lisfranc ligament (Figure 8, B). In cadaver speci- mens, this technique has been found to provide stability similar to that provided by screw fixation.40 A small-fragment cortical screw is placed across the intercuneiform joint; alternatively, an additional En- doButton may be used (Figure 8, B) to stabilize the disruption between the cuneiforms. When gross instability remains between the navicular and cuneiform following such fixation, the surgeon may need to add K-wire fixation across this joint. The wiring is removed prior to weight bearing. The postoperative protocol with the EndoButton is the same as that for screw or plate fixation, and removal is not needed. These alternative treatments have not been used by enough surgeons and for a long enough time to indicate whether they offer results com- parable or superior to those of traditional techniques. However, they Preoperative (A) and 2-year postoperative (B) AP weight-bearing radiographs may offer promise for reducing the of complete midfoot dislocation with minimal bony involvement (type A). The incidence of posttraumatic arthritis. ligamentous nature of the injury required the use of permanent dorsal plating. A modular hand plate was used. C, Lateral radiograph obtained at 2-year Further prospective studies are follow-up demonstrating good alignment with minimal degenerative change. needed to compare the various techniques. often useful for this technique, and of the postoperative course is similar, dorsal plate fixation has been shown less the need for hardware removal. Summary to be as biomechanically sound as Subtle Lisfranc injuries are the screw fixation.39 Painful hardware most difficult to diagnose and man- The diagnosis of subtle Lisfranc in- has not been a concern, and removal age. These injuries often have inter- jury may be delayed or missed alto- is not common with properly placed cuneiform extension, with the injury gether. Such injuries are predisposed low-profile plating systems. Weight exiting through the medial naviculo- to chronic instability, deformity, and bearing is advanced rapidly, similar cuneiform facet (Figure 8, A). Most pain.12,31,36 Salvage includes ORIF or to screw fixation, and the remainder surgeons believe that pure ligamen- arthrodesis with the goal of restoring

726 Journal of the American Academy of Orthopaedic Surgeons Troy S. Watson, MD, et al

Figure 8 fixation should be attempted. When the adequacy of the reduction is questionable, the surgeon should not hesitate to perform open reduction. Screw fixation remains the traditional fixation technique, although there is evidence to suggest that primary arthrodesis may be superior for the purely ligamentous midfoot injury.36 Future studies should involve newer fixation techniques and compare them with traditional surgical techniques.

References

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