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Surgical Pearls

Beware Of The Proximal Variant With Subtle Lisfranc Injuries

Lisfranc injuries occur in one in 55,000 people in the United States, comprising 0.2 percent of all adult fractures as well as 17 percent of pediatric injuries.1-4 These injuries are typically associated with high-energy trauma such as automotive accidents.5-8 

However, the subtle Lisfranc injury occurs with a more insidious or low-energy insult. The literature has shown that up to 20 percent of Lisfranc injuries are missed in the emergency department.9,10 A missed subtle Lisfranc injury without adequate treatment can lead to a progressive collapse of the midfoot and post-traumatic arthrosis (see photo at the right). 

Understanding The Mechanism Of Lisfranc Injuries 

The Lisfranc ligament begins on the lateral aspect of the medial cuneiform and extends to the medial aspect of the second metatarsal. The Lisfranc ligament is eight to 10 mm long and five to six mm thick. It consists of dorsal, interosseous and plantar attachments. This ligament is charged with stabilizing the medial column and preventing divergence of the medial and central columns.11-12 

Injuries to the Lisfranc joint complex consist of two main categories. The first is direct impaction, which is often the case in crush injuries with plantar subluxation of the tarsometatarsal joint. The second category involves indirect injury that can occur with twisting or torqueing of the forefoot while it is still in contact with the ground. The heel is elevated off the ground, which results in axial forefoot loading. This force leads to dorsal subluxation of the forefoot complex. Often, these indirect injuries can result from missteps or simple falls. They can even appear as “high energy” injuries in osteopenic bone. 

The more common higher energy injuries often result from automobile accidents or falls from a height that are generally more severe and affect the entire Lisfranc joint complex. For the purposes of this column, we will take a closer look at lower energy injuries that are more subtle. These injuries primarily affect the medial and central columns, and specifically affect the Lisfranc ligament, which provides stability to the midfoot.8,9,13-15 

Classifying Lisfranc Injuries And Understanding Subtle Injury Stratification 

Nunley and Vertullo formally described classification of subtle Lisfranc injuries in three stages based on the degree of injury to the components of the Lisfranc ligament in 2002.16 This classification system, which is exclusive to subtle injuries, includes stage I involving dorsal ligament disruption that does not lead to compromise or instability of the Lisfranc complex (see second photo above). 

Stage II involves both the dorsal and interosseous portions of the band, but not the plantar aspect of the ligament. This can lead to subtle destabilization between the medial cuneiform and second metatarsal base, but in general, the complex remains intact. The first metatarsal-medial cuneiform joint remains stable. Surgical intervention is often advisable due to only the tenuous plantar portion remaining intact. This can compromise anatomic stability, reducing the ability to maintain the integrity of the transverse arch.16,17 

Stage III injuries demonstrate a complete tear of the ligament, including the plantar portion. Destabilization of the medial and central columns occur either as “latent” or “frank” injuries. Latent injuries appear relatively normal anatomically and radiographically, but subluxation occurs with weightbearing and on abduction stress radiographs. Frank injuries appear unstable radiographically even without weightbearing. Stage III injuries are also accompanied by first metatarsal-medial cuneiform instability.16-17 

There are also proximal variants of these injuries. Crates and team describe medial cuneiform rotation and widening without evidence of incongruity of the navicular-medial cuneiform complex, which is a “positive notch sign” (see third photo above).18 The alignment of the second metatarsal base to the intermediate cuneiform remains intact. This represents a dorsal and interosseous ligament tear (stage II injury) without compromise of the plantar ligament. Stabilization involves a “home run” Lisfranc screw from the medial cuneiform to the second metatarsal base as well as an intercuneiform screw from the medial cuneiform to the intermediate cuneiform.16 

Myerson and colleagues also describe a proximal variant extending into the medial column with a diastasis greater than five mm between the medial and intermediate cuneiform joints. This is known as a positive “candle flame” sign (see bottom photo above).9 This injury then exits out of the navicular-medial cuneiform joint. 

Originally described by Turco and Spinella in 1982, this variant also exhibits a lateral shift of the second metatarsal base on the intermediate cuneiform.19 Anatomically, the plantar ligament is partially torn along with the dorsal medial cuneiform-navicular ligament. First metatarsal instability would subsequently translate to the navicular-medial cuneiform joint. Surgical stabilization should include the medial cuneiform-navicular joint in this variant. 

Key Diagnostic Factors And Imaging For Lisfranc Injuries 

Misdiagnosis of subtle Lisfranc injury occurs in nearly 20 to 50 percent of cases when clinicians use non-weightbearing radiographs.12,20 A patient must be more than 50 percent weightbearing to demonstrate full loading of the Lisfranc ligament.21 Fluoroscopic stress exams are also useful in diagnosing a subtle Lisfranc injury but guarding and discomfort may introduce the possibility of a false negative exam. Anesthesia may mitigate this concern.19, 21-22 

When examining the dorsoplantar view of the foot, one should visualize the medial and lateral borders of the first metatarsal to identify any step-off with the medial cuneiform. The first metatarsal and medial cuneiform should remain congruent on the lateral view. On a dorsoplantar view, the second metatarsal base should align with the intermediate cuneiform. A fleck sign may be present due to avulsion fracture either from the second metatarsal base or the medial cuneiform. The third metatarsal medial base should align with the medial aspect of the lateral cuneiform. If any incongruity exists, it would represent a stage III injury. 

Stage II injuries are more subtle as only a diastasis of two to five mm exists between the medial cuneiform and the second metatarsal base, and the plantar ligament remains intact enough to stabilize the Lisfranc complex. It is important to be aware of the proximal variants with the positive notch sign and the candle flame sign. 

Magnetic resonance imaging (MRI) is especially useful when a patient cannot tolerate weightbearing and stress X-rays, or when radiographs and/or computed tomography (CT) are negative despite clinical suspicion of injury. Magnetic resonance imaging provides the ability to elucidate all ligaments that comprise the band of the Lisfranc complex, a distinct advantage over all other forms of imaging.10,19,23-25 

Computed tomography is an invaluable imaging modality for Lisfranc injuries as it plays an important role in evaluating the articular surfaces. One can assess derangement and intra-articular involvement, which is critical when considering open reduction and internal fixation (ORIF) versus primary arthrodesis.19-20, 26-27 

Palpable pain and subtle edema are very indicative of midfoot Lisfranc injury although subtle injuries may vary in presentation. Plantar ecchymosis of the midfoot may exist but is not always present acutely.28 First tarsometatarsal sagittal instability is often present with disruption of the Lisfranc ligament complex. Clinically, one may note a positive “piano key” sign where the patient expresses discomfort with sagittal range of motion. This sign may be present in classic first tarsometatarsal stage III injuries or in proximal variants with naviculocuneiform instability. Patients often have difficulty with heel rise or toe-off.28 The clinical and imaging presentations should collectively lead the physician to identify a subtle Lisfranc ligament injury. 

A Guide To Conservative And Surgical Management Of Subtle Lisfranc Injuries 

One reserves conservative management of a subtle Lisfranc trauma for stage I dorsal ligament injuries. Crates and team recommend the use of a short leg walking orthosis or CAM boot with progressive weightbearing as tolerated for six weeks.18 Moracia-Ochagavía and colleagues recommend non-weightbearing in a splint for six weeks with subsequent X-rays and progressing to weightbearing in a CAM boot as tolerated.29-30 

Surgical management, whether it is open or percutaneous, applies to stage II and III injuries. The percutaneous approach is indicated within two weeks of injury and is more ideal for stage II injuries where reinforcement of the plantar ligament occurs. One may employ a “home run” screw in a “non-lag” fashion to avoid joint compression. 

Historically, surgeons chose screw fixation but Alberta and colleagues note articular damage caused by 3.5 mm screws that varied from two to 4.8 percent of the articular surface.31 As a result, spanning plates have become more standard as a form of ORIF but reportedly have no difference in alignment with physiologic loading. A 2019 study noted that orthopaedic cases recently submitted for board certification show a significant increase in spanning plates over traditional ORIF.32 

The percutaneous approach is less useful for stage III injuries and proximal variants involving the navicular-medial cuneiform joint. Interposition of the torn ligament and capsule can occur, leading to incomplete and/or loss of reduction. Surgeons often employ a home run screw in fixation of stage III injuries. It is critical to stabilize and clear capsule and ligament to allow proper reduction. One then stabilizes the first metatarsal-medial cuneiform joint with a spanning plate as well as the second metatarsal-intermediate cuneiform joint if it is involved. 

Proximal variants of the navicular-medial cuneiform joint will require stabilization of that joint and the more distal joints as well. The proximal variant with medial column rotation and a notch sign will also require screw fixation from the proximal medial cuneiform to the intermediate cuneiform. Involvement of the medial cuneiform and navicular will involve a plate along the medial side of the joint.5, 26, 28, 32, 33 

Determining A Surgical Plan: ORIF Versus Primary Arthrodesis 

Controversy regarding open reduction and internal fixation (ORIF) versus primary arthrodesis began when Coetzee published his landmark article in 2008.17 Primary arthrodesis is certainly indicated for intra-articular fractures. However, the debate surrounds purely ligamentous stage III injuries. Coetzee found that ORIF yielded a 75 percent re-operation rate.17 This included hardware removal and conversion to arthrodesis. In this series, Coetzee found that primary arthrodesis performed better at every time interval in comparison to ORIF.17 

Other than the work by Coetzee, remaining studies find equivalent but not superior functional outcomes when comparing ORIF with primary arthrodesis.32 Primary arthrodesis is not without complications. Nonunion can occur in up to 33 percent of cases and adjacent joint degenerative joint disease reportedly occurs in up to 12 percent of cases.32 

Also, combinations of fixation exist in hybrid forms of ORIF. Surgeons can reduce the central column with anatomic spanning plates and then perform a primary fusion of the first tarsometatarsal joint.34 Additionally, in regard to the proximal variant involving the naviculocuneiform joint, primary arthrodesis can stabilize the first ray and prevent further peritalar collapse. 

What You Should Know About The Midfoot Flatfoot 

In the experience of the senior author, failure to distinguish stage II and III injuries can lead to a rigid form of flatfoot with the apex at the first metatarsal-cuneiform joint. Stage II injuries can evolve to stage III injuries with weightbearing and the tenuous plantar ligament “giving way.” The chief component of stage III injuries is first metatarsal-cuneiform instability. Loss of longitudinal arch height occurs solely through the now hypermobile first through third tarsometatarsal joints. 

Although equinus occurs due to the shortened lever arm, peritalar collapse does not occur unless a proximal variant is present, including the navicular-medial cuneiform joint. The lateral X-ray view will show subluxation of the first metatarsal base on the medial cuneiform and the fifth metatarsal base being level with the medial cuneiform. The deformity is rigid due to the geometry of the Lisfranc joint despite increased mobility creating the deformity. 

Management of the midfoot flatfoot includes fusion of the first through third tarsometatarsal joints and often gastrocnemius recession. The inherent mobility of the fourth and fifth tarsometatarsal joints is necessary for adaptation to terrain and are not typically involved in the fusion process. These joints are mobile adaptors and operate independent of the subtalar and midtarsal joints. 

Final Thoughts 

Lisfranc joint complex injury continues to be important within podiatric and orthopaedic literature. Emerging imaging and fixation technology show promise but requires further research. Open reduction internal fixation persists as a primary surgical solution in comparison to arthrodesis for a purely subtle ligamentous injury. It is imperative that the podiatric surgeon understands the risks and benefits of all modes of fixation, and is able to differentiate a subtle injury from a benign X-ray. Beware of the proximal variant as it can lead to a worsened prognosis and residual peritalar deformity. 

Dr. Visser is the Director of the Podiatric Residency Program at SSM Health DePaul Medical Center in St. Louis. He is a Fellow of the American College of Foot and Ankle Surgeons and a Diplomate of the American Board of Podiatric Medicine. 

Dr. Wolfe is a second-year resident at SSM Health DePaul Medical Center in St. Louis. 

Surgical Pearls
By H. John Visser, DPM, FACFAS and Joshua Wolfe, DPM, MHA

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Additional Reference 

35. Stavrakakis IM, Magaraki GE, Christoforakis Z. Percutaneous fixation of Lisfranc joint injuries: A systematic review of the literature. Acta Orthop Traumatol Turc. 2019;53(6):457-462.

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