having me here today, I'm gonna speak to you about Lisfranc injuries in athletes. These are my disclosures. So Jacques Lisfranc was a general in Napoleon's army and he described a midfoot amputation for gangrene. Today, the definition of Lisfranc injuries would be any bony or ligamentous injury involving the tarsomen and tarsal joints. It's important to remember that there are multiple variants and as you will see during this talk, there are multiple varieties of this injury pattern. So the ligamentous anatomy is very important here. There are transverse ligaments that connect the second through fifth metatarsal bases and then there's the Lisfranc ligament connecting the second metatarsal base to the medial cuneiform, leaving the first and second metatarsal bases as a relative area of weakness. The osseous anatomy is important as well. The second metatarsal base is recessed, creating a mortise to the midfoot. The stability of the midfoot is very much dependent on that recessed second metatarsal. So the mechanism of injuries, we can divide these into direct and indirect forces. A direct is typically high energy. That would be a dorsal to plantar directed force at the midfoot. These create atypical fracture patterns which are primarily bony. The second mechanism of injury would be an indirect mechanism where the forefoot is flexed. This would be more common, maybe similar to a turf toe injury. These often create purely ligamentous injuries. Again, in football, it's a cleated athlete. It's an axial load to the back of the heel with the foot fixed to the ground. So very common in cleated athletes. As you can see here on these cadaveric specimens, you can see the axial load created on the left and then the rotational force created on the right. So it's these two mechanisms that really create this non-contact ligamentous midfoot injury. And you can see as well in this live game video, it's the twisting component with the forefoot fixed in the ground that can create this kind of very unique midfoot injury. So the classification system here was actually first described in the early 1900s, later modified by Dr. Mark Meyerson to discuss a more proximal extension of the injury, and that's very common in NFL-level athletes. So there are a wide variety of injury patterns that are possible. In fact, these are both midfoot, what we would call midfoot or Lisfranc-type injuries. So important to remember that these can present in many different ways. The diagnosis, especially in cleated athletes, can sometimes be very subtle. They can have painful weight bearing. They can have swelling and point tenderness at the second metatarsal base. They can have difficulty with single limb rise. I really like this actually during the game to ask a player to single limb rise. If they can't, I have more concerns about a midfoot injury. One of our most important physical exam findings is for plantar ecchymosis. So that can be a very, at least sensitive test to examine for a more significant midfoot injury. The direct types can be more obvious. So radiographs are probably the initial and mandatory part of the workup. We want to get AP, lateral, and oblique views of the foot, and I have a very low threshold for obtaining contralateral films for comparison because some of these injuries can be very subtle and can often be missed. So typically, these would be standing radiographs if feasible, and we're gonna look very closely at the first TMT joint, the second TMT joint, the space between the first and second metatarsal bases, in addition to the intercuneiform joint, which you see here, which can be diastased in these more proximal injuries, as well as step-off at the naviculocuneiform joint. So all of these areas should be very closely inspected on plain radiograph. On the oblique view, you can get a very clean look at the second, third, and fourth TMT joints, again, looking for any subtle fracture patterns or step-offs. And on the lateral view, you're looking for dorsal subluxation of the metatarsal bases. In particular, the first and second TMT joints can be visualized on the lateral weight-bearing radiograph. You may see a flex sign, which is an avulsion of the second metatarsal base from Lisfranc ligament. A standing AP is a really nice stress test, especially if you don't have access to fluoroscopy, single limb if feasible. So you can see the difference between a non-weight-bearing and a single-limb weight-bearing radiograph showing the diastasis at the second metatarsal base. Compression of the cuboid, or the so-called nutcracker cuboid, can be seen in more high-energy type injuries, as well as metatarsal neck fractures or MP dislocations. It's also important to recognize that there is proximal extension of the force in some of these injuries, including step-off at that naviculo-cuneiform joint. So this was described by our mentor, Dr. Bob Anderson. And these are more severe injury patterns, which can lead to unstable first ray, difficulty with push-off, and with any displacement. These typically do require surgery. So stress testing, either static or with fluoroscopy, is very important in evaluating these injuries. You can place an abduction force on the forefoot, which can destabilize the first and second TMT joints. And you can see here, kind of a live view, you can see that first and second TMT joint instability in a more significant mid-foot injury. So CT scan, it's not routinely done in my practice. I do like to use CT if I'm trying to predict who may require a primary arthrodesis or a fusion of the mid-foot, versus an open-reduction internal fixation. So you can look very closely at articular comminution or intra-articular fractures of the metatarsal bases. MRI can be helpful if there's vague presentation. It can locate the extent of the injury. It's a static test, it's non-weight-bearing. But it can confirm the ligamentous disruption. I think it's particularly helpful in athletes. Our treatment goal in treating these injuries surgically is to stabilize the injured joints. We want to eliminate risk for progression. If it's a stable injury pattern, typically it would be four to six weeks of non-weight-bearing either in a short-leg cast or a boot, and then repeat radiographs to ensure stability. Typical return would probably be eight to 12 weeks. Surgical indications, there's no specific parameters. Each patient is treated individually. Do they have pain? Do they have difficulty with push-off or single-limb rise? Is there diastasis on radiographs? Is there an unstable pattern confirmed by stress testing? So these are all the considerations to determine who may or may not benefit from surgery. I think it's important to remember this kind of landmark study by Mark Meyerson in 1984, where he had four-year follow-up on 55 patients with mid-foot injuries, and he found a close correlation between the quality of reduction and clinical outcome. When we think about fixation of these injuries, there's really two options. There are transarticular screws, or screws that cross the joints, versus dorsal bridge plating or joint-sparing techniques. This is a nice study from JBJS British looking at 108 patients who had ORIF with transarticular screws or joint-sparing techniques, and there were significantly superior clinical outcomes in the 45 patients treated with dorsal bridge plating. This technique is well-supported in the biomechanical literature as well. This is a nice study by our friend Tom Harris out of UCLA, where he compared 13 cadaveric specimens using transarticular screws or dorsal bridge plating, and he found equivalent strength in both groups, suggesting that dorsal bridge plating is a safe alternative to transarticular screws preserving the articular cartilage. The surgical technique here, we tend to expose and clean the joints. We reduce with a clamp, and then we place our fixation from medial to lateral. Once the first, second, and third TMT joints have been stabilized, we can then consider fixation of the fourth and fifth TMT joints, typically with a K-wire if needed. I would consider an X-fix for a lateral crush injury, and we reserve arthrodesis, or primary fusion, for patients with articular comminution, patients with increased age, or a high-energy type injury pattern. So for the dorsal plate, first you confirm the extent of the injury, then you reduce with a clamp, and place the dorsal plate with a provisional fixation, and then you place screws to maintain our reduction. So this was a 17-year-old male football player who presented to my office two days after the injury. You can see here the significant mid-foot dislocation. At surgery, you can see, essentially, the complete dislocation through the mid-foot and the instability. He was reduced and plated. I did use a K-wire for the fourth and fifth TMT joints to stabilize. At three months, he continued to maintain his reduction. We removed the hardware at five months. He went on to do quite well. This was a 30-year-old female. Again, one of these more subtle presentations. She had a trip and fall while hiking. She had significant mid-foot pain, had been in a boot with another provider, and you can see, again, that subtle diastasis of the second metatarsal base on her single-limb weight-bearing radiograph. So that's a very helpful test to help make these diagnoses in more subtle cases. You can see, at the time of surgery, her significant second TMT instability. You can see we're placing an abduction force on the foot, and you can see that excess movement at the second metatarsal base. And you'll see here, as we place the freer elevator, that we can easily subluxate the second metatarsal base. So that's true mid-foot instability. And she was fixed with that dorsal plate construct that I showed you earlier and went on to do quite nicely at six months. So when we think about return to sport in these active, young, healthy patients, I think it's important to remember and counsel our patients, athletes, as well as recreational athletes, that there may be some limitation in activity and ongoing symptoms despite surgery. So this is a nice study looking at 33 patients, average age 31, 94% return to activity, but 25% of these patients had at least some limitation and persistent symptoms. So again, very important to remember that patients may have some ongoing discomfort despite surgery. And I wanted to at least include one or two cases to show you some indications for primary arthrodesis. This is a 45-year-old male. He had undiagnosed mid-foot pain after falling from his car. So you can see that second metatarsal base fracture. It's intra-articular, and there's diastasis at the second metatarsal base. The CT scan shows the intra-articular second metatarsal base fracture. And so this, for me, is a nice indication for nitinol compression staples. So we drill and place our pins, and then we open our staple. We check it on fluoroscopy. And so now you can see that first TMT joint has been primarily fused with staple fixation, and we add additional fixation at the second and third TMT joints. So these are his five-month post-operative x-rays. He went on to do quite well. Again, a 30-year-old female who was crushed by a horse. You can see that intra-articular second metatarsal base fracture, which I think is quite impressive on the CT scan, showing intra-articular comminution. Again, a nice indication for primary arthrodesis. The outcomes of primary arthrodesis are actually quite good in young, healthy patients. So this is a well-done study out of HSS, retrospectively looking at 38 patients with primary arthrodesis of the first, second, and third TMT joints. And what they found was 97% return to activity. But again, 25% of those patients had at least some persistent symptoms. So very important to remember these issues when counseling our patients. In conclusion, I rely heavily on history, physical exam, and imaging studies when treating these patients. My primary treatment is ORIF and athletes, but I do reserve primary arthrodesis for patients with significant intra-articular comminution or greater patient age. Thank you.

Lisfranc injuries

athletes

diagnosis

treatment options

surgical intervention