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Efficacy of Ultrasound Imaging in the Evaluation of the Lisfranc Joint Complex

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Efficacy of Ultrasound Imaging in the Evaluation of the Lisfranc Joint Complex Efficacy of Ultrasound Imaging in the Evaluation of the Lisfranc Joint Complex THESIS Presented in Partial Fulfillment of the Requirements for the Degree Master of Science in the Graduate School of The Ohio State University By Meridith Kay DeLuca, B.S. Graduate Program in Anatomy The Ohio State University 2018 Master's Examination Committee: Laura C. Boucher, PhD, ATC (Advisor) Christopher Pierson, MD, PhD Bryant Walrod, MD Copyright by Meridith Kay DeLuca 2018 Abstract Lisfranc injuries account for 1 in 55,000 injuries yearly and are associated with poor outcomes and high complication rates. Located between the medial cuneiform and second metatarsal, the dorsal Lisfranc ligament is easily visualized with ultrasonography. Ultrasound can provide quick, cost effective diagnosis of pathology, but is not standardized in practice. The purpose of this study was to compare measurement accuracy of the dorsal Lisfranc ligament between ultrasound and gross dissection with an additional anatomic study of the complex, including the dorsal, interosseous, and plantar Lisfranc ligaments. Ultrasound images of 22 embalmed cadaveric feet (11 male, 7 female, 80.3 years ± 14.03) were obtained using a Sonosite M-Turbo ultrasound machine. The dorsal Lisfranc ligament was imaged and measured using a 6-13MHz linear array. Images were measured a second time using ImageJ software. Specimens were then dissected to evaluate the dorsal, interosseous, and plantar Lisfranc ligaments. Dorsal ligament measurements were compared between methodologies, and morphology of the joint complex was also recorded. Differences in measurement of the dorsal Lisfranc ligament between ultrasound imaging (8.39 mm ± 1.26) and gross dissection (10.80 mm ± 1.85) were significant (p < 0.001). ImageJ measurements (8.24 mm ± 1.84) did not differ from ultrasound i measurements, but were significantly different than dissection (p < 0.001). Dissection revealed the morphology of the dorsal and interosseous Lisfranc ligaments were consistent. The plantar ligament presented with variant morphology, demonstrating both a Y-shaped variant inserting separately on the 2nd and 3rd metatarsals, and a fan-shaped variant inserting across the metatarsals. A connection to the interosseous Lisfranc ligament was present in 64% of specimens. When compared to anthropometric measurements of the foot, no correlations were found with dorsal Lisfranc ligament length. Two specimens also possessed bony growths at the Lisfranc joint, raising questions regarding the prevalence of arthritis at the uninjured joint. While the dorsal Lisfranc ligament is easily distinguishable on ultrasound, these data indicate that only 70-80% of the ligament is visible due to difficulty distinguishing the boney attachments. Wide variation of the plantar Lisfranc ligament was also noted, which may play into the relative vulnerability of the joint complex in some patients. Further expansion of the current study could explore the differences between embalmed and fresh cadavers, and induced injury to cadaveric feet to compare ultrasound and dissection appearances of the injured Lisfranc joint complex. ii Dedication This document is dedicated to my friends and family. iii Acknowledgments This thesis would not have been possible without the guidance, encouragement, and patience of my advisor, Dr. Laura Boucher. From the beginning, Dr. Boucher recognized the vision I had for my research, and provided countless hours of assistance and mentorship, for which I am beyond grateful. I would also like to thank my committee members. Dr. Chris Pierson has been an invaluable resource and support during my entire graduate education. Dr. Bryant Walrod’s insight and expertise in sports medicine has proved critical in carrying out the vision I have for this project, and ensuring that its findings are clinically relevant. To Rachel Tatarski, I want to extend a special thank you for taking the time to be my research mentor and ultrasonography instructor. Additionally, I need to thank the friends and fellow students who provided hours of support and assistance at various stages of this project: Morgan Turnow, Kolin Korth, Meghan Flannery, Jay Vela, and Spencer Gardner. I also want to thank the Division of Anatomy, which has been crucial in providing me with the opportunities to further my knowledge of the human body. Finally, I thank the donors who participated in the Body Donation Program at The Ohio State University, without whom my anatomical education would not have been possible. iv Vita 2012................................................................Johannesburg-Lewiston High School, Johannesburg, Michigan 2016................................................................B.S. Biology, University of St. Francis 2016 to present ..............................................Graduate Student, Division of Anatomy, The Ohio State University Fields of Study Major Field: Anatomy v Table of Contents Abstract ................................................................................................................................ i Dedication .......................................................................................................................... iii Acknowledgments.............................................................................................................. iv Vita ...................................................................................................................................... v List of Tables ................................................................................................................... viii List of Figures .................................................................................................................... ix Chapter 1: Study Overview ................................................................................................. 1 List of Abbreviations ....................................................................................................... 4 Chapter 2: Background ....................................................................................................... 5 2.1: Anatomy of the Lisfranc joint complex ................................................................... 5 2.2: Lisfranc Injuries ..................................................................................................... 10 Mechanism of Injury .................................................................................................. 10 Diagnosis ................................................................................................................... 13 Injury Treatment ........................................................................................................ 15 Patient Outcomes ....................................................................................................... 15 2.3: Ultrasound imaging of the Lisfranc joint complex ................................................ 18 vi 2.4: Cadaveric Studies involving the Lisfranc Joint ..................................................... 20 2.5: Current Study ......................................................................................................... 20 Chapter 3: Methods ........................................................................................................... 22 3.1: Ultrasound Methods ............................................................................................... 23 3.2: Dissection Methods ................................................................................................ 25 3.3: Analysis .................................................................................................................. 28 Chapter 4: Results – Ultrasonography of the Dorsal Lisfranc Ligament.......................... 29 Chapter 5: Results – Dissection of the Lisfranc Joint Complex ....................................... 34 Chapter 6: Discussion ....................................................................................................... 42 6.1: Ultrasound Imaging ................................................................................................ 42 6.2: Cadaveric Dissection .............................................................................................. 44 6.3: Clinical Relevance ................................................................................................. 45 6.4: Limitations ............................................................................................................. 48 6.5: Future work ............................................................................................................ 52 6.6: Conclusions ............................................................................................................ 53 References ......................................................................................................................... 55 Appendix A: Data Tables.................................................................................................. 59 Appendix B: Ultrasound Scan Protocol ............................................................................ 65 Appendix C: Dissection Protocol...................................................................................... 66 vii List of Tables Table 1. Mean anthropometric measurements of the foot ................................................ 29 Table 2. Mean measurements of the DLL across modalities ............................................ 29 Table 3.
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