Treatment of the Missed Lisfranc Injury
Section snippets
Anatomy and biomechanics
The TMT joints consist of the five metatarsals and their articulation with the corresponding cuneiforms and cuboid. TMT joint stability comes from a combination of bone morphology, ligaments, and soft tissue support. The second metatarsal base forms a keystone with all three cuneiforms. The metatarsal bases, cuneiforms, and cuboid are wedge-shaped bones that form a stable “Roman arch” configuration. Ligaments cross the TMT, naviculocuneiform, and intercuneiform joints. Ligaments connect the
Mechanism of injury
Lisfranc injuries occur by direct and indirect mechanisms. Motor vehicle accidents and crush injuries are examples of dorsally or plantarly directed blows with a rotational component. The indirect mechanism of injury involves an axial force to a plantarflexed foot, usually with subsequent external rotation of the forefoot. Clinical examples include a fall on the stairs, a player landing on the posterior heel of an athlete's plantarflexed foot, and abduction of a foot fixed in a stirrup in
Clinical evaluation of acute Lisfranc injuries
In severe injuries with dislocation of the TMT joints there usually is significant pain, swelling, deformity, inability to bear weight, possible neurovascular compromise, and obvious radiographic findings. These injuries are rarely missed, with the possible exception of the patient who has experienced polytrauma, in whom a proper foot evaluation may be overlooked.
In subtle injuries there is pain, swelling, and tenderness, which often is limited to the area over the Lisfranc ligament.
Clinical presentation of missed Lisfranc injuries
Missed Lisfranc injuries may present weeks to years after the injury has occurred, but before posttraumatic arthritis has set in. The patient may have delayed or foregone medical treatment for what was considered to be a routine “foot sprain.” Alternatively, there may have been a delay in obtaining or interpreting appropriate diagnostic imaging studies correctly after acute evaluation with the diagnosis often not made by the original treating physician.
The patient also may present with a remote
Imaging
Weight-bearing AP, lateral, and 30° oblique radiographs should be taken with the x-ray beam angled parallel to the TMT joint surfaces for the AP and 30° oblique views, the ankle in dorsiflexion, and the knee in extension. This angle gives a clearer view of the TMT joints, averages about 17° from perpendicular to the floor, and can be determined for any given individual on their lateral radiograph. TMT joint subluxation that is associated with chronic Lisfranc joint instability may be absent on
Criteria for Lisfranc instability/malalignment
With rare exception [8], most studies suggest that outcome after Lisfranc injury improves with the quality of TMT joint reduction [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]. Multiple radiographic criteria for defining “unacceptable” displacement of an acute Lisfranc joint injury have been proposed; however, the amount of radiographic subluxation or displacement that exceeds the normal range or is associated with a poorer functional
Treatment options
Treatment options for the missed Lisfranc injury include nonoperative treatment, TMT joint realignment with joint preservation, arthrodesis, and arthroplasty. The goal is to obtain a minimally painful functional foot. Theoretically, this requires anatomic alignment of the midfoot joints and restoration of normal ligamentous stability. This preserves mechanical integrity of the arch and allows physiologic motion to dissipate load through the minimally mobile first, second, and third TMT joints
Nonoperative treatment
Immobilization in a cast or cam walker may be particularly helpful to promote ligament healing in patients whose injuries are only a few weeks or months old. An insole orthosis or University of California Biomechanical Laboratory brace can support the arch, accommodate fixed deformity, limit subluxation that is due to ligamentous instability, and decrease painful motion of arthritic joints. A shoe with a stiff rocker sole or cane may aid ambulation. Acetaminophen, glucosamine/chondroitin
Joint realignment procedures
Joint reconstruction is a viable option for patients who have residual Lisfranc joint instability or subluxation and minimal to mild arthritis (Fig. 1). The surgical principles are the same as for acute Lisfranc injuries, with the possible exception of a decreased role for closed reduction and internal fixation. It may still be possible to percutaneously reduce and stabilize the second metatarsal to the medial cuneiform. However, if the Lisfranc ligament has already healed in an elongated
Arthrodesis and arthroplasty
Arthrodesis is indicated for advanced arthritis or fixed or neuropathic deformity. Arthrodesis also may be considered over joint realignment and ligament reconstruction to reduce the risk of recurrent subluxation and progressive arthritis at the cost of loss of joint motion. If there is only malalignment at the second TMT joint an isolated arthrodesis of the second TMT and medial–intermediate intercuneiform joint may be performed through the same dorsomedial incision that is used for Lisfranc
Literature review and clinical decision making
Hardcastle and colleagues [17] noted only fair results in two patients who had Lisfranc joint injuries that were treated with open reduction and k-wire fixation more than 6 weeks after injury. They believed that it probably was better not to attempt reduction and fixation after 6 weeks from the date of injury. Faciszewski and colleagues [26] performed arthrodesis on two patients who presented at 4 months and 25 years after Lisfranc joint injury; the results were good and poor, respectively. One
Treatment recommendations
Lisfranc injuries that are at least 6 weeks old upon diagnosis, do not have associated fractures that require surgical stabilization, and do not meet radiographic criteria for significant TMT subluxation or instability are treated nonoperatively initially. Because first TMT joint hypermobility is not uncommon and often decreases secondary to postinjury scarring and immobilization, the author has a slightly higher threshold for sagittal plane motion of this joint in the absence of a history of
Summary
Lisfranc injuries, particularly subtle low-energy ones, may be missed at the time of injury and can leave the patient with persistent instability, deformity, and/or arthritis. In the presence of neuropathic arthropathy, significant residual arthritis, or fixed deformity that is recalcitrant to conservative treatment, arthrodesis, including correction of deformity, is the treatment of choice for the first, second, and third TMT joints. Usually, fourth and fifth TMT joints are treated by
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