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Introduction
  • A condition characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal
    • unifying factor is disruption of the TMT joint complex
    • injuries can range from mild sprains to severe dislocations
    • may take form of purely ligamentous injuries or fracture-dislocations
    • ligamentous vs. bony injury pattern has treatment implications
  • Epidemiology
    • incidence
      • account for 0.2% of all fractures
    • demographics
      • more common in the third decade
      • more common in males
  • Mechanism & Pathoanatomy
    • causes include MVAs, falls from height, and athletic injuries
    • mechanism is usually caused by indirect rotational forces and axial load through hyperplantar flexed forefoot 
      • hyperflexion/compression/abduction moment exerted on forefoot and transmitted to the TMT articulation
      • metatarsals displaced in dorsal/lateral direction
  • Associated conditions
    • proximal metatarsal fractures or tarsal fractures
      • Lisfranc equivalent injuries can present in the form of contiguous proximal metatarsal fractures or tarsal fractures
  • Prognosis
    • missed injuries can result in progressive foot deformity, chronic pain and dysfunction
      • tarsometatarsal fracture-dislocations are easily missed and diagnosis is critical
Anatomy
  • Osteology 
    • Lisfranc joint complex consists of three articulations including
      • tarsometatarsal articulation
      • intermetatarsal articulation
      • intertarsal articulations
  • Ligaments
    • Lisfranc ligament  
      • critical to stabilizing the second metatarsal and maintenance of the midfoot arch
      • An interosseous ligament that goes from medial cuneiform to base of 2nd metatarsal on plantar surface 
      • Lisfranc ligament tightens with pronation and abduction of forefoot
    • plantar tarsometatarsal ligaments
      • injury of the plantar ligament between the medial cuneiform and the second and third metatarsals along with the Lisfranc ligament is necessary to give transverse instability. 
    • dorsal tarsometatarsal ligaments
      • dorsal ligaments are weaker and therefore bony displacement with injury is often dorsal
    • intermetatarsal ligaments
      • between second-fifth metatarsal bases
      • no direct ligamentous attachment between first and second metatarsal
  • Biomechanics
    • Lisfranc joint complex is inherently stable with little motion due to
      • stable osseous architecture
        • second metatarsal fits in mortise created by medial cuneiform and recessed middle cuneiform, "keystone configuration"
      • ligamentous restraints
        • see individual ligaments above
  • Columns of the midfoot
    • medial column
      • includes first tarsometatarsal joint
    • middle column
      • includes second and third tarsometatarsal joints
    • lateral column
      • includes fourth and fifth tarsometatarsal joints (most mobile)
Classification
  • Multiple classification schemes described
    • none proven useful for determining treatment and prognosis
Physical Exam
  • Symptoms
    • severe pain
    • inability to bear weight
  • Physical exam
    • inspection & palpation
      • medial plantar bruising
      • swelling throughout midfoot
      • tenderness over tarsometatarsal joint
    • motion & stability
      • instability test
        • grasp metatarsal heads and apply dorsal force to forefoot while other hand palpates the TMT joints
          • dorsal subluxation suggests instability
          • if first and second metatarsals can be displaced medially and laterally, global instability is present and surgery is required
        • when plantar ligaments are intact, dorsal subluxation does not occur with stress exam and injury may be treated nonoperatively
    • provocative tests
      • may reproduce pain with pronation and abduction of forefoot
    • compartment syndrome
      • always check for compartment syndrome and take compartment pressures if high suspicion
Imaging
  • Radiographs
    • recommended views
      • AP, lateral, obliques
      • stress radiograph
        • may be helpful to show instability when non-weight bearing radiographs are normal and there is high suspicion
      • weight-bearing radiographs with comparison view
        • may be necessary to confirm diagnosis
    • findings
      • five critical radiographic signs that indicate presence of midfoot instability
        1. disruption of the continuity of a line drawn from the medial base of the second metatarsal to the medial side of the middle cuneiform
        2. widening of the interval between the first and second ray
        3. medial side of the base of the fourth metatarsal does not line up with medial side of cuboid on oblique view
        4. metatarsal base dorsal subluxation on lateral view
        5. disruption of the medial column line (line tangential to the medial aspect of the navicular and the medial cuneiform)
      • lateral  
        • non weight-bearing radiographs may show dorsal displacement of the proximal base of the first or second metatarsal  
      • AP  
        • malalignment of medial margin of the second metatarsal base and the medial edge of the middle cuneiform diagnostic of Lisfranc injury 
        • may see bony fragment (fleck sign) in first intermetatarsal space 
          • represents avulsion of Lisfranc ligament from base of 2nd metatarsal
          • diagnostic of Lisfranc injury 
      • oblique
        • malalignment of fourth metatarsal and cuboid
  • CT scan
    • useful for diagnosis and preoperative planning
  • MRI
    • can be used to confirm presence of purely ligamentous injury
Treatment
  • Nonoperative
    • cast immobilization for 8 weeks 
      • indications
        • no displacement on weight-bearing and stress radiographs and no evidence of bony injury on CT (usually dorsal sprains)
        • certain nonoperative candidates
          • nonambulatory patients
          • presence of serious vascular disease
          • severe peripheral neuropathy
          • instability in only the transverse plane
  • Operative
    • open reduction and rigid internal fixation 
      • indications
        • any evidence of instability (> 2mm shift)    
        • favored in bony fracture dislocations as opposed to purely ligamentous injuries
      • outcomes
        • anatomic reduction required for a good result
    • primary arthrodesis of the first, second and third tarsometatarsal joints
      • indications
        • purely ligamentous arch injuries 
        • delayed treatment 
        • chronic deformity
      • outcomes
        • level 1 evidence demonstrates equivalent functional outcomes and decreased rate of hardware removal or revision surgery compared to primary ORIF  
        • primary arthodesis is an alternative to ORIF in patients with any evidence of instability with possible benefits
        • medial column tarsometatarsal fusion shown to be superior to combined medial and lateral column tarsometatarsal arthrodesis
    • midfoot arthrodesis
      • indications
        • destabilization of the midfoot's architecture with progressive arch collapse and forefoot abduction
        • chronic Lisfranc injuries that have led to advanced midfoot arthrosis and have failed conservative therapy
Technique
  • General Surgical Considerations
    • equipment
      • fluoroscopy and radiolucent table
      • small fragment and mini fragment sets (2.0mm-4.0mm screws)
      • reduction clamps, k-wires, dental pick, Homan retractors
      • small battery powered drill
    • timing of surgery
      • emergently only if
        • the presence of compartment syndrome
        • open injury
        • irreducible dislocations
      • delay operative treatment until soft tissue swelling subsides (up to 2-3 weeks)
      • if grossly unstable and in presence of significant soft tissue swelling consider early external fixation
  • Open reduction and rigid internal fixation
    • approach
      • single or dual longitudinal incisions can be used based on injury pattern and surgeon preference
      • longitudinal incision made in the web space between first and second rays
      • first TMT joint is exposed between the long and short hallux-extensor tendons
    • reduction & fixation
      • reduce intercuneiform instability first
      • fix first through third TMT joints with transarticular screws
        • screw fixation is more stable than K-wire fixation 
    • postoperative care
      • early midfoot ROM, protected weight bearing, and hardware removal (k-wires in 6-8 weeks, screws in 3-6 months
      • gradually advance to full weight bearing at 8-10 weeks
      • if patient is asymptomatic and screws transfix only first through third TMT joints, they may be left in place
      • preclude return to vigorous athletic activities for 9 to 12 months
  • Primary arthrodesis of the first, second and third tarsometatarsal joints
    • arthrodesis & fixation
      • expose TMT joints and denude all joint surfaces of cartilage
      • use cortical screws to fuse joints
    • postoperative care
      • apply cast or splint for 6 weeks
      • progress weight bearing between 6 and 12 weeks in removable boot
      • full weight bearing in standard shoes by 12 weeks post-op
  • Midfoot arthrodesis
    • arthrodesis & fixation
      • expose TMT joints and midfoot  and remove cartilage from first, second, and third TMT joints
      • add bone graft
      • reduce the deformity using windlass mechanism
      • variety of definitive fixation constructs exist
    • postoperative care
      • touch down weight bearing in a cast for 6 weeks
      • begin weight bearing at 10 weeks if evidence of healing is noted on radiographs
Complications
  • Posttraumatic arthritis
    • most common complication
    • may cause altered gait and long term disability
    • treat advanced midfoot arthrosis with midfoot arthrodesis
  • Nonunion
    • uncommon
    • revision surgery indicated unless patient is elderly and low demand
 

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Questions (10)

(OBQ13.32) A 35-year-old motorcyclist is involved in a motor vehicle accident. He complains of pain and swelling in his right foot. Examination demonstrates dorso-medial midfoot tenderness. A clinical photograph is seen in Figure A. Supine and standing radiographs are seen in Figures B and C respectively. What is the most appropriate definitive treatment step? Review Topic

QID:4667
FIGURES:
1

Non-weightbearing in a CAM walker boot for 6-10 weeks

1%

(19/2454)

2

Weightbearing as tolerated in a CAM walker boot for 6-10 weeks

0%

(10/2454)

3

Closed reduction and K-wire fixation of the first and second tarsometatarsal joints

2%

(49/2454)

4

Open reduction and rigid internal fixation of the first and second tarsometatarsal joints

78%

(1909/2454)

5

Open reduction and rigid internal fixation of the first to third tarsometatarsal joints and K-wire fixation of the fourth and fifth tarsometatarsal joints

19%

(459/2454)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

This patient has a ligamentous Lisfranc injury to the 2nd tarsometatarsal (TMT) joint (seen as displacement on stress views) and 1st TMT joint (seen as medial gapping on stress views, without frank displacement). Open reduction is preferred over closed reduction. Fixation should be with screws or joint spanning plates and screws.

Lisfranc fracture dislocations are caused by hyperflexion/compression/abduction moments at the forefoot, leading to dorso-lateral metatarsal displacement, most commonly involving at least the 2nd TMT joint. Where non-weightbearing radiographs are normal and there is high clinical suspicion, weightbearing stress radiographs are indicated. Any evidence of instability (lateral shift) is an indication for ORIF.

Watson et al. reviewed the treatment of Lisfranc injuries. Nonsurgical management should only be for patients with minimal ambulation, insensate feet or pre-existing inflammatory arthritis. Treatment is then weightbearing as tolerated in a CAM walker boot for 6-10 weeks.

Rammelt et al. examined a cohort of patients with primary ORIF vs secondary arthrodesis (for malunion/untreated Lisfranc injuries). There was greater satisfaction with primary ORIF. They concluded that primary ORIF leads to greater functional results/satisfaction, but secondary arthrodesis remains a useful salvage procedure.

Figure A shows plantar bruising and swelling characteristic of a Lisfranc injury. Figure B shows a supine AP radiograph with normal bony alignment. Figure C is a weight-bearing stress AP radiograph showing lateral subluxation of the 2nd TMT joint, and medial gapping of the 1st TMT joint without lateral shift. Illustration A is a table showing the indications of surgery following specific investigations.

Incorrect Answers
Answers 1,2: This injury demonstrates subluxation on stress views. This is an indication for surgery.
Answer 3: Open reduction is preferred over closed reduction to allow visualization of the reduction, loose osteochondral fragments and soft-tissue interposition. Preferred fixation of the medial 3 TMT joints is with screw or plate fixation.
Answer 5: Open reduction is preferred. Rigid fixation of 1-3 TMT joints and K-wiring of 4-5 TMT joints is indicated if there is injury to all 5 TMT joints; such as in a homolateral lisfranc dislocation. The lack of subluxation at the other TMT joints suggests otherwise.

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(OBQ12.13) A 25-year-old male sustains a left foot injury while playing soccer. His radiographs are shown in figures A and B. Which of the following techniques would lead to the best outcome when addressing his injury? Review Topic

QID:4373
FIGURES:
1

Rigid cast immobilization

3%

(95/3662)

2

Spanning medial column external fixation

0%

(18/3662)

3

Percutaneous screw fixation of medial column of foot

6%

(209/3662)

4

K-wire fixation of medial column of foot

2%

(67/3662)

5

Open reduction and internal fixation of medial column of foot

89%

(3257/3662)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The clinical presentation is consistent with a Lisfranc injury, or tarsometatarsal fracture dislocation. Open reduction and internal fixation of the medial column of the foot is the most appropriate treatment.

A Lisfranc injury is characterized by disruption between the articulation of the medial cuneiform and base of the second metatarsal. While different fracture patterns occur, the unifying factor is disruption of the TMT joint complex. During surgical fixation of these injuries, ORIF with cortical screw fixation would allow more rigid construct than casting, or Kirshner wire fixation. Therefore, the construct with the most cortical screws would be most stable and rigid.

Lee et al. performed a biomechanical cadaver study looking at different constructs for Lisfranc fixation. The biomechanical stability of three fixation methods was tested: (1) four Kirschner wires, (2) three cortical screws plus two Kirschner wires, and (3) five cortical screws. Their results showed that multiple cortical screw fixation provided the most rigid and stable method of fixation for Lisfranc injuries as compared to Kirschner wire fixation. They concluded that this fixation method would allow maintenance of anatomic reduction and possibly earlier mobilization with a decreased risk of posttraumatic arthrosis.

Figures A and B show noncongruency and displacement between the first and second tarsometatarsal joints consistent with a Lisfranc injury. Illustration A shows successful ORIF of a Lisfranc injury using multiple cortical screws for a rigid construct. Illustration B illustrates the position of the Lisfranc injury which spans from the plantar/lateral aspect of the medial cuneiform to the plantar/medial aspect of the second metatarsal.

Incorrect Answers:
Answers 1-4: These forms of treatment do not provide the same rigid construct as ORIF with screws for Lisfranc injuries.

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(OBQ11.185) A 40-year-old male sustains a right foot injury after a head-on motor vehicle collision. He is unable to place weight on the foot to ambulate due to pain along the medial aspect of the foot. The pain is exacerbated with abduction of the midfoot. The patient denies pain along the lateral border of the midfoot. He is neurovascularly intact in the foot. An injury radiograph is shown in Figure A, while a clinical image of the foot is shown in Figure B. What is the most appropriate next step in management? Review Topic

QID:3608
FIGURES:
1

Open reduction and arthrodesis of the medial two tarsometatarsal joints

55%

(1196/2183)

2

External fixation of the foot followed with staged open reduction and screw fixation across the medial two tarsometatarsal joints

2%

(44/2183)

3

Open reduction and screw fixation across the medial three tarsometatarsal joints and percutaneous pinning of the 4th and 5th tarsometatarsal joints

26%

(565/2183)

4

Debridement of Morel-Lavallee lesion and external fixation of the foot followed with staged open reduction and screw fixation across the medial two tarsometatarsal joints

1%

(16/2183)

5

Open reduction and screw fixation across the medial two tarsometatarsal joints with anatomic ligamentous reconstruction

16%

(358/2183)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The history, clinical images, and radiographs are consistent with a Lisfranc injury. Instability of the Lisfranc joint is the result of injury to both the interosseous first cuneiform-second metatarsal ligament (Lisfranc's ligament) and the plantar ligament between the first cuneiform and the second and third metatarsals.

Ly and Coetzee performed a Level 1 investigation of 41 patients with an isolated acute or subacute Lisfranc dislocation treated with ORIF or primary arthrodesis of the medial column of midfoot. Two years postoperatively, the mean AOFAS Midfoot score was 68.6 points in the open-reduction group and 88 points in the arthrodesis group (p < 0.005). Postoperative level of activities was significantly higher in the arthrodesis group and 25% of the ORIF group required a subsequent revision to an arthrodesis. They concluded that primary arthrodesis of the medial two or three rays has a better short and medium-term outcome than ORIF.

Henning et al conducted a Level 1 investigation of 40 patients with a Lisfranc fracture/dislocation treated with either ORIF or primary arthrodesis. They found that nearly 80% of the ORIF group needed subsequent hardware removal compared to 15% of the arthrodesis group. They found no statistical difference in functional outcomes at nearly 4 year follow-up. They concluded that there is no significant difference in SF-36 and Short Musculoskeletal Function Assessment outcome scores when compared to ORIF.

The deep neurovascular bundle (as shown in Illustration A) should be protected following its identification after skin incision . Illustration B is an example of a tarsometatarsal arthrodesis with the medial three joints fused.

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(OBQ09.244) A 24-year-old man sustains an injury to his left foot. Stress radiographs are seen in Figure A. Injury to which ligament or ligaments are needed to produce the transverse instability seen here? Review Topic

QID:3057
FIGURES:
1

Spring ligament and bifurcate ligament

1%

(21/1514)

2

Interosseous first cuneiform-second metatarsal ligament

31%

(473/1514)

3

Interosseous first cuneiform-second metatarsal ligament and plantar ligament between the first cuneiform and the second and third metatarsals

60%

(905/1514)

4

Bifurcate ligament and Interosseous first cuneiform-second metatarsal ligament

4%

(67/1514)

5

Long plantar ligament and plantar ligament between the first cuneiform and the second and third metatarsals

3%

(46/1514)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

Transverse instability of the Lisfranc joint is the result of injury to both the interosseous first cuneiform-second metatarsal ligament (Lisfranc's ligament) and the plantar ligament between the first cuneiform and the second and third metatarsals.

Figure A shows a ligamentous Lisfranc injury.

Kaar et al performed a cadaveric study in which sequential sectioning of the Lisfranc ligament followed by the plantar ligament between the first cuneiform and the second and third metatarsals was performed in order to simulate a low energy Lisfranc injury with transverse instability . Stress abduction radiographs were positive for all specimens in which both ligaments were sectioned, while sectioning of just the Lisfranc ligament was positive for only one specimen.

Incorrect answers: The other options would not lead to a Lisfranc injury with transverse instability.


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(OBQ08.139) As an alternative to open reduction and internal fixation for the injury pattern seen in Figure A, what alternative treatment has been shown to be more effective? Review Topic

QID:525
FIGURES:
1

open reduction and arthrodesis of the medial and middle column, reduction and stabilization of the lateral column

83%

(1309/1569)

2

open reduction and primary arthrodesis of the medial, middle, and lateral columns

9%

(145/1569)

3

closed percutanous pinning of the medial, middle, and lateral columns

6%

(88/1569)

4

closed reduction of the midfoot and casting

1%

(23/1569)

5

partial weight bearing in removable boot

0%

(3/1569)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The lateral radiographs shows a ligamentous Lisfranc injury. There does not need to be a fracture to be called a Lisfranc injury; and the ligamentous ones typically have even worse outcomes than similar fracture-type injuries. These uniformly have poor, painful outcomes if treated non-operatively because recurrence of the dislocation occurs without rigid bony fixation to allow soft tissues to heal. Typically, these have been treated with ORIF, but outcomes are often poor and many times the deformity recurs because the soft tissues may not heal strong enough to resist weight bearing forces, as compared to fractures which are strong once healed.

Ly et al. published a prospective, randomized study of ORIF alone versus ORIF with primary arthrodesis for patients with primarily ligamentous Lisfranc injuries. In the ORIF alone group, 16 of 20 had revision surgery, with only 4 of 21 needed revision surgery in the fusion group, and the fusion group had significantly better functional outcomes at 2 years.

The referenced study by Mulier et al compared ORIF versus arthrodesis and noted the ORIF group had less pain at final follow-up, with no differences in subsequent revision surgery. Stiffness of the forefoot, loss of metatarsal arch, and sympathetic dystrophy occurred more frequently in the complete arthrodesis group. They concluded that primary complete arthrodesis should be reserved as a salvage procedure.


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(OBQ08.222) Which ligament connects the medial cuneiform to the base of the second metatarsal? Review Topic

QID:608
1

Spring ligament

1%

(18/1270)

2

Chopart ligament

0%

(6/1270)

3

Lisfranc ligament

97%

(1236/1270)

4

Intermetatarsal ligament

1%

(8/1270)

5

Calcaneofibular ligament

0%

(1/1270)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

The Lisfranc ligament arises from the lateral surface of the medial cuneiform and inserts onto the medial aspect of the second metatarsal base near the plantar surface. It is the largest and strongest interosseous ligament in the tarsometatarsal joint complex. The spring ligament (plantar calcaneonavicular ligament) is a broad, thick band of fibers, which connects the anterior margin of the calcaneus to the navicular. It supports the head of the talus and helps maintain the medial longitudinal arch of the foot.

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(OBQ07.103) A 37-year-old man was involved in a high velocity motor vehicle accident 6 months ago. He spent 4 months in the ICU recovering from a severe head injury. He has now transitioned to a rehabilitation hospital and complains of left foot pain that becomes severe with weightbearing and attempted ambulation. Radiographs are provided in figures A-C. Which of the following is the best management? Review Topic

QID:764
FIGURES:
1

Custom orthotics and physical therapy

0%

(2/633)

2

Closed reduction and percutaneous screw fixation of 1st through 3rd tarsometatarsal joints

2%

(14/633)

3

Open reduction internal fixation of 1st through 3rd tarsometatarsal joints

22%

(140/633)

4

Arthrodesis of 1st through 3rd tarsometatarsal joints

70%

(446/633)

5

Tarsometatarsal arthrodesis and triple arthrodesis

5%

(29/633)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

The clinical presentation and radiographs present a Lisfranc (tarsometatarsal dislocation) injury that is 6 months old. The first, second, and third tarsometatarsal articulations are involved. Given the chronicity of the injury, arthrodesis is the best treatment option available to relieve pain and improve function. There is no indication to include a triple arthrodesis with the tarsometatarsal arthrodesis.

The Mulier article compared total arthrodesis (medial + lateral) vs medial column arthrodesis with lateral column ORIF for severe Lisfranc injuries. They found inferior outcomes with total arthrodesis.

Komenda et al reviewed 32 patients who underwent tarsometatarsal arthrodesis at a minimum of 6 months following injury. The patients improved significantly compared to the preoperative pain and function. However, a number of complications were encountered including neuritis, malunion, nonunion, wound sloughing, and RSD.



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(OBQ06.100) A 30-year-old equestrian caught her foot in a stirrup 1 week ago and now complains of midfoot pain with difficulty bearing weight. Radiographs are shown in figure A. What treatment is most appropriate? Review Topic

QID:211
FIGURES:
1

Non-weight bearing in an aircast

2%

(34/1370)

2

Weight bearing as tolerated in a walking cast

2%

(27/1370)

3

Modified-Brostrom procedure

1%

(14/1370)

4

Delayed corrective osteotomy and arthrodesis of the medial column

1%

(16/1370)

5

Arthrodesis of the medial tarsometatarsal joints

93%

(1276/1370)

Select Answer to see Preferred Response

PREFERRED RESPONSE 5

The patient has a Lisfranc injury. These are typically high energy injuries involving the Lisfranc ligament which connects the base of the 2nd metatarsal to the medial cuneiform. Dorsal dislocation is most common form. Anatomic reduction is necessary and can only reliably be achieved through open reduction and internal fixation. The ligament or a bony avulsion can become incarcerated in the joint preventing anatomic reduction. Following surgery patients should be treated with protected weight-bearing for 3-5 months and therapy emphasizing passive midfoot ROM. Midfoot post traumatic arthritis and pain are the long term outcomes of a non-anatomically reduced joint. Regardless when considering fusion or ORIF, operative reduction must be done.

Kuo et al showed less arthritis and better AOFAS scores with anatomic ORIF. The subgroup of patients with purely ligamentous injury showed a trend toward poorer outcomes even with anatomical reduction and screw fixation.

Ly and Coetzee performed a Level 1 investigation of 41 patients with an isolated acute or subacute Lisfranc dislocation treated with ORIF or primary arthrodesis of the medial column of midfoot. Two years postoperatively, the mean AOFAS Midfoot score was 68.6 points in the open-reduction group and 88 points in the arthrodesis group (p < 0.005). Postoperative level of activities was significantly higher in the arthrodesis group and 25% of the ORIF group required a subsequent revision to an arthrodesis. They concluded that primary arthrodesis of the medial two or three rays has a better short and medium-term outcome than ORIF.

Henning et al conducted a Level 1 investigation of 40 patients with a Lisfranc fracture/dislocation treated with either ORIF or primary arthrodesis. They found that nearly 80% of the ORIF group needed subsequent hardware removal compared to 15% of the arthrodesis group. They found no statistical difference in functional outcomes at nearly 4 year follow-up. They concluded that there is no significant difference in SF-36 and Short Musculoskeletal Function Assessment outcome scores when compared to ORIF.


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(OBQ06.132) A 54-year-old male sustained a right foot injury two years ago in a motor vehicle collision. The patient reports he was treated for a ligament injury in his foot with a non-weightbearing short leg cast for 2 months. Physical examination reveals no signs of infection and full sensation and motor strength in the foot. During gait examination he has pain during push-off of the right foot and loss of medial longitudinal arch height in the stance phase. A radiograph obtained at the time of initial injury is shown in Figure A. What is the most appropriate next step in management? Review Topic

QID:318
FIGURES:
1

Lateral column lengthening procedure (Evans)

5%

(16/349)

2

Tarsometatarsal joint arthrodesis

89%

(309/349)

3

Talonavicular joint arthrodesis

3%

(10/349)

4

Lateral wedge closing calcaneal osteotomy (Dwyer)

1%

(3/349)

5

Subtalar, talonavicular, and calcaneocuboid joint arthrodesis (Triple)

3%

(10/349)

Select Answer to see Preferred Response

PREFERRED RESPONSE 2

The patient's clinical presentation is consistent with a chronic Lisfranc injury with posttraumatic midfoot arthritis. Figure A shows an acute Lisfranc injury with diastasis between the medial cuneiform and 2nd metatarsal.

The Lisfranc joint complex consists of tarsometatarsal, intermetatarsal, and intertarsal articulations. The Lisfranc ligament goes from medial cuneiform to base of 2nd metatarsal on plantar surface and provides transverse foot stability.

The Level 5 review article by Thompson and Mormino state that shoe inserts/modifications and nonsteroidal anti-inflammatory medications are the mainstay of non-surgical treatment for posttraumatic arthritis after Lisfranc injury. If these modalities fail, arthrodesis of the affected joints is the treatment of choice.

Illustration A shows the anatomic postion of the stout, plantar portion Lisfranc ligament with the deep band spanning from the medial cuneiform to the 2nd metatarsal and the superficial band extending to the 3rd metatarsal

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(OBQ04.1) A 54-year-old woman sustains a twisting injury to her foot. A radiograph is provided in Figure A. Which of the following is the most appropriate treatment? Review Topic

QID:112
FIGURES:
1

closed reduction and pinning

4%

(33/849)

2

closed reduction and casting

1%

(11/849)

3

open reduction and internal fixation

93%

(788/849)

4

CAM walker and weight bearing as tolerated

2%

(15/849)

5

weight bearing as tolerated

0%

(1/849)

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PREFERRED RESPONSE 3

This is a Lisfranc injury. No consensus exists about optimal treatment of these injuries, but evidence is clear that a satisfactory result is directly related to the accuracy of the reduction and its successful maintenance through healing. Some recent studies support primary fusion over ORIF as optimal treatment for purely ligamentous injuries; however, this is not an answer choice. Many authors recommend open reduction and screw fixation for treatment of all TMT fractures and dislocations. Alterations in the anatomy of the Lisfranc joints secondary to trauma can result in foot collapse and altered weight bearing which are difficult to salvage later.


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