OBJECTIVE: To assess if Lisfranc injury can be detected by US with and without abduction stress.
METHODS: Eight cadaveric feet were obtained. The following measurements were obtained in the uninjured feet: C1M2 and C1C2 intervals and TMT1 and TMT2 dorsal step-off distances. Measurements were obtained both with and without abduction stress using ultrasound. The injury model was created by transecting the Lisfranc ligament complex, after which the observers performed the measurements again. Statistical analysis was used to identify differences between intact and injured models, to determine diagnostic cut-off values for identifying Lisfranc injuries, and to assess interobserver/intraobserver reliability.
RESULTS: There was a significant difference in the mean C1M2 interval, both with and without abduction stress, between the intact and torn Lisfranc ligament (p < 0.001). A C1M2 interval with stress of > 2.03 mm yielded 81% sensitivity and 72% specificity for Lisfranc disruption. There was no significant difference in the mean C1C2 interval of the torn versus intact Lisfranc ligament without stress (p = 0.10); however, the distance was significantly different with the application of stress (p < 0.001). The C1C2 interval of > 1.78 mm yielded 72% sensitivity and 69% specificity for Lisfranc injury under stress. There were no significant differences in the mean TMT1 or TMT2 dorsal step-off measurements between the intact and torn Lisfranc ligaments. All observers showed good intraobserver ICCs. The interobserver ICCs for all measurements were good or excellent, except for TMT1, which was moderate.
CONCLUSIONS: Ultrasonography is a promising point-of-care imaging tool to detect Lisfranc ligamentous injuries when measuring C1M2 and C1C2 distances under abduction stress.

UNASSIGNED: Lisfranc injuries are often treated with open reduction and internal fixation using rigid fixation techniques. The use of flexible fixation to stabilize the Lisfranc joint is a newer technique. The purpose of this cadaveric study is to compare the amount of diastasis at the Lisfranc interval under diminished physiologic loads when treated with a knotless suture tape construct and a solid screw.
UNASSIGNED: Ten cadavers (20 feet) had native motion at the intact Lisfranc interval assessed at multiple increasing loads (69, 138, and 207 N). The Lisfranc ligamentous complex was then disrupted, and testing repeated to evaluate the amount of diastasis. Randomization was performed to determine the type of fixation for each cadaver: solid screw or knotless suture tape construct. Once fixation was completed, specimens were cyclically loaded for 10 000 cycles at loads, and diastasis was quantified after each load cycle to compare the interventions. Diastasis was measured using motion tracking cameras and retroreflective marker sets. A non-inferiority statistical analysis was performed.
UNASSIGNED: Diastasis mean values were confirmed to be >2 mm for all load bearing conditions in the injury model. Posttreatment, diastasis was significantly reduced when compared to the sectioned conditions (P < .01) for both treatment options. Non-inferiority analyses showed that the knotless suture tape construct did not perform inferior to screw fixation for diastasis at the Lisfranc interval at any of the compared load states.
UNASSIGNED: Under the loads tested, there is no significant difference in diastasis at the Lisfranc interval when treating ligamentous Lisfranc injuries with a knotless suture tape construct or solid screws. Both reduced diastasis from the injured state and were not different from the intact state.
UNASSIGNED: In this cadaveric model with ligamentous Lisfranc injury, diastasis of a knotless suture tape construct is compared to solid screw fixation as tested.

UNASSIGNED: There is no consensus whether the primary surgical method should be open reduction and internal fixation (ORIF) or primary arthrodesis (PA) for Lisfranc injuries. The aim of our randomized controlled trial was to compare ORIF and PA for displaced Lisfranc injuries.
UNASSIGNED: This study was a national multicenter randomized controlled trial. Altogether 43 displaced Lisfranc injuries were enrolled in this trial. The primary outcome measure was Visual Analogue Scale Foot and Ankle (VAS-FA) at a 24-months follow-up. The secondary outcome measures were VAS-FA pain, function, and other complaints subscales and the American Orthopaedic Foot & Ankle Society (AOFAS) Midfoot Scale. All outcomes were measured at 6, 12, and 24 months. We were unable to reach the planned sample size of 60 patients; thus, the study remains underpowered.
UNASSIGNED: The mean VAS-FA Overall score in the ORIF group was 86.5 (95% CI 77.9, 95.1) and 80.1 (95% CI 72.0, 88.1) in the PA group at the 24-month follow-up. We did not find eligible evidence of a difference in VAS-FA Overall scores (mean between-group difference 6.5 [95% CI -5.3, 18.2], Cohen d = 0.100).
UNASSIGNED: We did not find evidence of a difference in VAS-FA between ORIF and PA in patients with displaced Lisfranc injuries, and thus both are viable options for the initial surgical method. The trial is underpowered; however, the data may be included in a meta-analysis of similarly designed randomized controlled trials.ClinicalTrials.gov identifier: NCT02953067 24 October 2016.

OBJECTIVE: To determine from a patient perspective what improves the quality of care and patient satisfaction during the treatment and recovery process of Lisfranc fractures and to reveal possible points for improvement in this process.
METHODS: We performed a qualitative study based on semi-structured interviews with patients treated for a Lisfranc fracture-dislocation in the Netherlands with either open reduction and internal fixation or primary arthrodesis, until data saturation was reached, focusing on the quality of care during treatment and recovery, from a patient perspective.
RESULTS: Data saturation was reached after interviewing 10 patients. The main themes emerging from the analysis were expectation management regarding the recovery period; communication with and between health care providers; information provided during consultations; and support during the recovery period. Participants expressed a need for improved provision of information about the different treatment options, the different kinds of pain that can arise, the expected duration of the recovery period, education on strong pain killers, likelihood of a second surgery, risks of osteoarthritis, risks of the surgery itself, allied health care and patient experiences. Participants mentioned the importance of good allied health care and a preference for starting allied health care as soon as possible. Insoles and compression socks were also appreciated by various participants. Finally, multiple patients saw a positive attitude on the part of the health care providers towards the recovery period as a key factor in recovery.
CONCLUSIONS: This study found that patients value more tailored approaches to the pre-and post-operative care program, more guidance regarding allied health care (physiotherapy), and a broader scope of available references and information for patients, both oral (during consultations and in informative videos) and written, such as brochures or evidence-based web pages and mobile platforms, which may be offered during consultations or when being discharged from the hospital.

Open reduction and internal fixation (ORIF) is a popular method for treatment of displaced Lisfranc injuries. However, even with anatomic reduction and solid internal fixation, treatment does not provide good outcomes in certain severe dislocations. The purpose of this study was to compare ORIF and primary arthrodesis (PA) of the first tarsometatarsal (TMT) joint for Lisfranc injuries with the first TMT joint dislocation.
Seventy-eight Lisfranc injuries with first TMT joint dislocation were finally enrolled and analyzed in a prospective, randomized trial comparing ORIF and PA. They were 50 males and females with a mean age of 40.7 years and randomized to ORIF group and PA group. Outcome measures included radiographs, American Orthopaedic Foot and Ankle Society (AOFAS) midfoot scale, Foot and Ankle Ability Measure (FAAM) Sports subscale, visual analog scale (VAS), and the 36-Item Short Form Health Survey (SF-36). Complications and revision rate were also analyzed.
Forty patients were treated by ORIF, while PA group includes 38 cases. Patients were followed up for 37.8(range, 24-48) months. At final follow-up, the mean AOFAS midfoot score (P < 0.01), the FAAM Sports subscale (P < 0.01), the physical function score (P < 0.05), and the Bodily Pain score of SF-36 (P < 0.05) after ORIF treatment were significantly lower than PA group. The mean VAS score in ORIF group was higher (P < 0.01). In ORIF group, redislocation of the first TMT joint was observed in ten cases, and thirteen patients had pain in midfoot. No redislocation and no hardware failure were identified in PA group.
PA of the first TMT joint provided a better medium-term outcome than ORIF for Lisfranc injuries with the first TMT dislocation. Possible complications and revision could be avoided by PA for dislocated first ray injuries.

BACKGROUND: The aim of this study was to evaluate the outcome after nondisplaced and stable Lisfranc injuries.
METHODS: 26 patients with injuries to the Lisfranc joint complex detected on CT scans, but without displacement were tested to be stable using a fluoroscopic stress test. The patients were immobilized in a non-weightbearing short leg cast for 6 weeks. The final follow-up was 55 (IQR 53-60) months after injury.
RESULTS: All the Lisfranc injuries were confirmed to be stable on follow-up weightbearing radiographs at a minimum of 3 months after injury. Median American Foot and Ankle Society (AOFAS) midfoot score at 1-year follow-up was 89 (IQR 84-97) and at final follow-up 100 (IQR 90-100); The AOFAS score continued to improve after 1-year (P=.005). The median visual analog scale (VAS) for pain was 0 (IQR 0-0) at the final follow-up. One patient had radiological signs of osteoarthritis at 1-year follow-up.
CONCLUSIONS: Stable Lisfranc injuries treated nonoperatively had an excellent outcome in this study with a median follow-up of 55 months. The AOFAS score continued to improve after 1 year.

Unstable Lisfranc injuries are best treated with anatomic reduction and stable fixation. There are controversies regarding which type of stabilization is best. In the present study, we compared primary arthrodesis of the first tarsometatarsal (TMT) joint to temporary bridge plating in unstable Lisfranc injuries.
Forty-eight patients with Lisfranc injuries were included and followed for 2 years. Twenty-four patients were randomized to primary arthrodesis (PA) of the medial 3 TMT joints, whereas 24 patients were randomized to temporary bridge plate (BP) over the first TMT joint and primary arthrodesis of the second and third TMT joints. The main outcome parameter was the American Orthopaedic Foot & Ankle Society (AOFAS) midfoot scale and the secondary outcome parameters were the 36-Item Short Form Health Survey (SF-36) and visual analog scale for pain (VAS pain). Computed tomography (CT) scans pre- and postoperatively were obtained. Radiographs were obtained at follow-ups. Pedobarographic examination was performed at the 2-year follow-up. Twenty-two of 24 patients in the PA and 23/24 in the BP group completed the 2-year follow-up.
The mean AOFAS midfoot score 2 years postoperatively was 89 (SD 9) in the PA group and 85 (SD 15) in the BP group (P = .32). There were no significant differences between the groups with regard to SF-36 or VAS pain scores. The alignment of the first metatarsal was better in the BP group than in the PA group measured by the anteroposterior Meary angle (P = .04). The PA group had a reduced peak pressure under the fifth metatarsal (P = .047). In the BP group, 11/24 patients had radiologic signs of osteoarthritis in the first TMT joint.
Both treatment groups had good outcome scores. The first metatarsal was better aligned in the BP group; however, there was a high incidence of radiographic osteoarthritis in this group.
Therapeutic level I, prospective randomized controlled study.

The purpose of this study was to define the fracture type and investigate the injuries related to single medial, intermediate, or lateral cuneiform fracture.
From January 2008 to December 2018, 30 consecutive patients (30 cases) who were treated in the single institution for the single cuneiform fractures were reviewed retrospectively. Each fracture was categorized by location and type (intra- or extra-articular avulsion, axial compression, and direct blow). We also investigated the related foot bone fractures or dislocations on the affected side.
Twenty-one, one, and eight cases with single medial, intermediate, and lateral cuneiform bone fractures, respectively, were identified. More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. The single medial cuneiform fracture was associated with various types of foot injuries including Lisfranc injury, naviculo-cuneiform joint dislocation, or calcaneo-cuboidal dislocation. Single lateral cuneiform fractures were more frequently observed than single intermediate cuneiform fractures.
More than two-thirds of the single cuneiform fractures were observed in the medial cuneiform bone. Most intra-articular avulsion fractures were associated with high-energy trauma.
4.

BACKGROUND: Tarsometatarsal joint complex (TMC) is the anatomical structure of midfoot composed by metatarsals, tarsometatarsal (TMT) joints, cuneiforms, cuboid and navicular. TMC lesion are rare but critical since they cause severe disability if misdiagnosed. The knowledge of anatomic pattern of the lesion and biomechanics of the midfoot is the key for a successful diagnosis and treatment. The aim of this study was to review a consecutive series of TMC injuries analyzing preoperative radiograph and CT scan to accurately define the pattern of ligament and bone injuries.
METHODS: We reviewed a series of 24 complete TMC injuries with homolateral dorsolateral dislocation. The total TMT joints involved were 120. We observed if the lesions were pure ligamentous or fracture-dislocation detecting the extent and the location of fractures. Twenty-nine lesions (24%) were pure dislocations and they were mainly localized in the first and fifth ray. The fracture-dislocations were 91 (76%) and 25 were fractures of the proximal row (cuneiforms and cuboid), 39 of the distal row (metatarsals), 27 of both the distal and proximal row.
RESULTS: Proximal fracture had a homogeneous distribution and they were more frequently simple than comminuted. Comminuted fractures were more frequent in the cuboid. In the proximal row, majority of partial articular fractures were localized in the dorsal side. Fracture-dislocations of the distal row were more frequent in the second metatarsal base (100%) and the partial articular fractures were always placed in the plantar side. In TMC injuries fracture-dislocations are more frequent than pure dislocations. Pure dislocations occur more often in the marginal rays that are characterized by weaker ligaments and larger mobility. The second ray, where there is the more stable joint of TMC, was never dislocated with a pure ligamentous lesion.
CONCLUSIONS: We suppose that plantar avulsion from the distal row and dorsal compression fracture of the proximal row is consistent with a direct force applied to the forefoot and direct dorsolaterally. The direction of the forces may explain why some fractures occur in the distal row, some in the proximal and some in both rows. The thickness of plantar ligaments may explain the frequency of plantar bone fragment avulsion.

BACKGROUND: This study assessed the surgical outcomes of Lisfranc injuries accompanied by multiple metatarsal fractures. Metatarsal fractures here refers to metatarsal head, neck, and shaft (including shaft fractures accompanied by fractures of the base) fractures, as well as mixed (i.e., segmental fracture) fractures, as seen on imaging studies.
METHODS: Between 2002 and 2015, one hundred and seventy-six patients were followed-up for a mean of 92 months, including eight patients who underwent secondary arthrodesis due to severe arthritis after ORIF. All the patients underwent surgical fusion (primary partial arthrodesis, PPA; n = 78) or non-fusion (percutaneous or open reduction and internal fixation, ORIF; n = 98) procedures and the outcomes were evaluated by clinical examinations, radiography, visual analogue scale (VAS) pain score, the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score, the Foot and Ankle Outcome Score (FAOS), and the Short Form (SF)-36 physical and SF-36 mental questionnaires. The parameters between the fusion and non-fusion groups were analyzed by repeated-measures ANOVA. Statistically significant differences between the two groups were then further analyzed using a two-independent-samples t-test.
RESULTS: Anatomical reduction was achieved in 161 patients. At the last follow-up, the mean AOFAS score was 74.67 (range: 39-91) in the non-fusion group and 82.79 (range: 67-97) in the fusion group (P = 0.003). The PPA and ORIF groups differed significantly with respect to the VAS pain score (1.93 vs. 1.21), the SF-36 physical (75.87 vs. 80.90) and mental (75.76 vs. 81.33) components, and the FAOS pain (72.74 vs. 84.06), symptoms (71.87 vs. 82.49), activities of daily life (ADLs: 73.12 vs. 81.54), sport/recreation (sport/rec: 57.99 vs. 73.23), and quality of life (QoL: 79.95 vs. 86.67) components. In the ORIF group, 23 patients had mild/moderate post-traumatic osteoarthritis.
CONCLUSIONS: With longer and more conservative postoperative management, fusion results in a better outcome than non-fusion in the treatment of Lisfranc injuries accompanied by multiple metatarsal fractures.