Introduction
Lisfranc injuries comprise a large number of conditions ranging from dislocations
to subtle patterns that are diagnosed only with special examinations, taking into
account that approximately 20% of injuries are not diagnosed.[1] It has been described that the cause of these injuries can be both high-energy traumas,
with motorcycle accidents and falls from a height being frequent, and low-energy ones.[1] The consequences of not diagnosing them can impact the patients' quality of life,
since they include midfoot instability, arch collapse, and posttraumatic osteoarthritis
that leads to stiffness, pain, and dysfunction. These injuries are frequently associated
with complications such as compartment syndrome, which can further worsen the prognosis,
so early diagnosis and management are essential.[2]
The management of Lisfranc injuries is still controversial, considering that these
injuries are rare. There are no high-evidence studies that conclude that one type
of management is superior to another. The use of arthrodesis was initially generalized
to the majority of patients; however, in young patients the trend has been changing
because it limited mobility and predisposed to pathologies in adjacent structures.[3] The surgical treatment must be individualized, and the choice of implant will depend
on the patient and the personality of the osteoligamentous injury, with the objective
of achieving the greatest stability possible.
The objective of the present study is to report two complex cases of patients from
the Orthopedics and Traumatology Service of our hospital with a diagnosis of complex
Lisfranc fracture dislocation with tension hematomas, both subjected to open reduction
and internal fixation with different osteosynthesis materials following the recommendations
established in the literature[16] regarding the diagnosis and management of said pathology. Results were observed
at 3, 6, and 18 months of follow-up. In addition, we performed an updated review of
the diagnosis and treatment of Lisfranc lesion.
The following cases are presented because it is a topic that is in full development,
since new forms of diagnosis and treatment are continually being described, with new
medical material, which are having good results. In this case, we combined several
fixation methods rarely seen in the current literature[15], among which are tarsometatarsal plates locked with screws, headless compression
screws, the suspensory system, and Kirschner wires. Furthermore, the cases herein
reported present a complexity rarely seen in reviewed articles.
Case Presentation
Clinical case 1
A 31-year-old male patient, with no significant history, presented to the emergency
room with an illness of approximately 2 hours due to a motorcycle accident as a rider.
He reported that, after braking suddenly, the motorcycle fell on his left foot, causing
intense pain, with immediate increase in volume and functional impotence.
The patient was evaluated, and significant swelling in the affected foot (++ +/+ + + ),
deformity in the midfoot, and partial loss of sensation were confirmed. A radiographic
study was performed, and it showed a fracture of the first metatarsal associated with
a dorsal dislocation of the Lisfranc joint, which involved all the tarsometatarsal
joints. In the anteroposterior view, we could see that the medial edge of the second
metatarsal did not align with the medial edge of the intermediate cuneiform, > 2 mm
of distance between the base of the first metacarpal and the second metatarsal, as
well as between the first cuneiform and the base of the second metatarsal, and the
avulsion bone fragment of Fleck. On the lateral radiograph, we observed that the dorsal
and plantar edges of the metatarsals did not align with the edges of the cuboid and
cuneiform ([Figure 1]).
Fig. 1 Anteroposterior, oblique, and lateral foot X-rays upon admission to hospital after
the accident.
The patient was submitted to emergency surgery 3 hours after the accident, with release
of tension fracture hematomas, plus reduction and internal fixation of the Lisfranc
lesion with Kirschner wires, as damage control. When making the incision medially
to the shaft of the second metatarsal with proximal extension, a sudden decompression
of purplish soft tissue was evident ([Figure 2A]). A large fracture hematoma was released, a profuse lavage was performed with 5
liters of saline solution, and, finally, open reduction of the fracture dislocation
under verification with a C-arm, and 2-mm Kirschner wires were placed to stabilize
the midfoot ([Figure 3]). The surgical wound was not closed.
Fig. 2 and 4 (A) Release of tension fracture hematomas, reduction and fixation with Kirschner wires
3 hours after the accident. (B) Surgical cleaning 3 days after the intervention. Notable reduction in pain, paresthesia
and edema.
Fig. 3 Anteroposterior and lateral foot radiographs after open reduction and internal fixation
with Kirschner wires.
Fig. 2 and 4
The patient showed significant clinical improvement following the intervention, with
strict monitoring and management of soft tissues. Three days later, surgical debridement
was performed, revealing a reduction in edema and improved coloration of the soft
tissue ([Figure 4B]); four days after the intervention, the patient was admitted to the operating room
for definitive closure of the surgical wound until the definitive surgery.
After 12 days, after the edema had significantly decreased, and surgery had been planned
with the help of a computed tomography scan, the Kirschner wires were removed in a
second stage, and a definitive osteosynthesis was performed using the previous approach.
The Lisfranc complex was reduced with the help of a pointed clamp, aligning the joint
between the first and second cuneiforms, and fixing it with a 4-mm headless compression
screw, following the steps of guide wire insertion, measuring, drilling, and countersinking.
Then, the first tarsometatarsal joint was fixed with a dorsal locking plate with 4
holes. After this, the medial cuneiform was reduced with the base of the second metatarsal
with a pointed clamp, and a suspensory system (button) was placed, simulating the
Lisfranc ligament. Immediately afterwards, dorsal locking tarsometatarsal plates with
4 holes were used in the next 2 joints after reduction, placing cortical screws proximally
to the joint to direct them away from it, while the locking screws were placed distally.
Fixation of the fourth metatarsal with the cuboid was performed with a 4-mm headless
compression screw, while the fifth metatarsal was fixed with the cuboid using a 2-mm
Kirschner wire. All of the procedures described were performed using the C-arm guide
([Figure 5]).
Fig. 5 (A, B) Radiographs of definitive osteosynthesis of Lisfranc dislocation fracture. (C) Having fixed the medial wedge with the intermediate wedge using a headless compression
screw and the first metatarsophalangeal joint with a locked anatomical plate, the
button was introduced from the base of the second metatarsal to the medial edge of
the first wedge, simulating the Lisfranc ligament.
Clinical case 2
An 18-year-old male patient was admitted with an illness of 2 hours, characterized
by a fall from a height of 2 meters, with apparent axial load on the left midfoot
in plantar hyperflexion, resulting in intense pain and immediate inability to walk.
The physical examination revealed significant swelling, shiny and tense skin, diffuse
pain on palpation, partial loss of sensitivity, and plantar ecchymosis. ([Figure 6A]).
Fig. 6 (A) Soft tissue involvement, shiny and tense skin. (B) Anteroposterior and oblique radiographs of the left foot upon hospital admission.
Through a radiographic examination, we confirmed a Lisfranc fracture dislocation using
the radiographic signs described in the literature[17], as well as diaphyseal fractures of multiple metatarsals ([Figure 6B]). The patient was scheduled for emergency surgery 2 hours after admission for the
release of tense fracture hematomas, and open reduction and internal fixation. An
incision was made medially to the diaphysis of the second metatarsal and another laterally
to the diaphysis of the fourth metatarsal, both with proximal extension, evidencing
sudden release of purplish soft tissue and release of significant blood content from
the compartments. Direct reduction was performed with pincers, and 2-mm Kirschner
wires were used. One of these wires fixes the joint between the cuneiforms, another
simulates the Lisfranc ligament, extending from the first cuneiform to the base of
the second metatarsal, and another fixes the first cuneiform to the first metatarsal,
and retrograde Kirschner wires are placed through the diaphysis of the metatarsals
([Figure 7]). The incisions were left open, and the patient was scheduled for surgical cleaning
and closure 3 days later, showing good progress.
Fig. 7 Fixation of Lisfranc joint and multiple metatarsal fractures with Kirchner wires.
At the 2-week follow-up, sutures were removed from both patients, and physical therapy
was initiated. At 6 weeks, the Kirschner wires were removed in both cases after radiographic
evidence of consolidation, and partial weight-bearing was also started at this time.
By the third postoperative month, the patients reported no pain while walking longer
distances.
Collaboration with the Department of Physical Medicine and Rehabilitation helped in
recovering muscle strength by the sixth month. At the 18-month follow-up, both patients
were observed walking without support and without symptoms, with improved muscle trophism
and joint range of motion, evaluated using 3 validated scores. Both scored 82 on the
36-Item Short Form Health Survey (SF-36; scale from 0 to 100, in which a higher score
indicates better physical function). The first patient scored 17% on the Foot Function
Index (FFI), while the second scored 14% (scale from 0% to 100%, in which a higher
percentage indicates worse function and greater disability).[4]
Discussion
To discuss Lisfranc injuries, it is important to note that they involve the tarsometatarsal,
intermetatarsal, and anterior intertarsal joints. Lisfranc injuries can range from
severe fracture dislocations to subtle ligamentous injuries or a combination of both.[1] Historically, Lisfranc fracture dislocations are related to the Napoleonic Wars,
in which French gynecologist Jacques Lisfranc cared for soldiers injured in battle.
He encountered a case in which a soldier's foot became trapped in the stirrup after
falling from a horse, leading to foot swelling and subsequent gangrene. Lisfranc performed
an amputation at the level of the tarsometatarsal.[1] Over time, the concept of Lisfranc injury has evolved to characterize disruption between the medial cuneiform and the base
of the second metatarsal joint.
The incidence is of approximately 1 in every 55 thousand people/year, representing
0.1 to 0.4% of all fractures, with men in their third decade of life being the most
affected, as in the cases herein presented.[5]
[6] It is worth mentioning that 20% of Lisfranc lesions are overlooked or misdiagnosed.[6]
The injury can originate from a high-energy trauma (collision in a car or motorcycle,
falls from a height, impact sports such as soccer and windsurfing) and low-energy
trauma, such as simple slips or falls, often being confused with a sprain.[5]
[6] Patients with this injury often experience polytrauma.[7] The cases herein presented involved high-energy trauma, one as a motorcycle rider
and the other from falling off the second floor of a building.
The Lisfranc joint represents the transition from the midfoot to the forefoot, which
is essential for normal walking. Anatomically, the Lisfranc joint is considered to
have three longitudinal columns: the medial column consists of the medial cuneiform
and the base of the first metatarsal; the intermediate column includes the intermediate
cuneiform and the lateral cuneiform with the bases of the second and third metatarsals;
and the lateral column comprises the cuboid with the bases of the fourth and fifth
metatarsals, which is the most mobile.[7]
[8] The bases of the metatarsals form a Roman arch in the axial cut, with the second
metatarsal being a crucial part. It articulates proximally with the second cuneiform
and also makes contact with the first and third cuneiforms.[8] There are several ligaments involved in the Lisfranc joint complex: intermetatarsal
ligaments (dorsal, interosseous, and plantar); plantar and dorsal tarsometatarsal
ligaments; and the Lisfranc ligament itself, which extends from the base of the medial
cuneiform to the plantar surface of the second metatarsal, playing a crucial role
in maintaining stability and alignment of the midfoot.[6] This ligament is very strong, long, and crucial for stabilizing the second metatarsal.
In addition to connecting the medial column with the intermediate one, it maintains
the arch of the midfoot and restricts the bone mobility of the foot.[6] Stability is largely achieved through the second cuneometatarsal joint (the second
metatarsal is firmly embedded within the tarsus and must fracture to completely dislocate).[5] The mechanism of Lisfranc fracture dislocation generally involves direct or indirect
forces or axial loading on the midfoot in hyperflexion or plantar flexion, often combined
with forced abduction.[6] Isolated ligamentous injuries are associated with low-energy traumas, whereas bone
fractures are typically present in motor vehicle accidents and falls from heights.[6] Male subjects suffer from these injuries 2 to 4 times more often.[8] In the cases herein presented, there were not only ligamentous injuries (intermetatarsal,
tarsometatarsal, Lisfranc), but also bone fractures, indicating the high energy of
the trauma, as described.
The clinical presentation is variable, since it depends on the severity of the Lisfranc
lesion. In the anamnesis, the common denominator is pain in the midfoot and, as the
severity of the injury increases, other inflammatory signs such as edema and swelling
in that area appear, in addition to functional limitation, which hinders standing
up. On physical examination, local heat is palpable in the midfoot and plantar ecchymosis
can often be present. Provocative maneuvers must be performed to evaluate stability,
such as pronation, supination, adduction, abduction, loading with one foot, and passive
mobility of the three columns in the coronal and sagittal planes.[8] It is essential to perform a neurovascular assessment, which includes confirming
the dorsalis pedis pulse, considering that it may be compromised by the dislocation
of the second metatarsal.[6] Both Chopart and Lisfranc dislocations are frequently associated with compartment
syndrome of the foot, and the incidence of this complication is of 25% and 34% respectively.[2] Therefore, the symptoms and clinical signs of said pathology must be continually
evaluated.
Regarding the radiological diagnosis, both radiography, computed tomography and magnetic
resonance imaging are useful.[5] Anteroposterior, lateral and internal oblique 30-degree X-rays must be requested,
all of these with loading and comparisons.[8] When not performed with weight-bearing, 20 to 50% of subtle Lisfranc injuries go
unnoticed.[8] In the anteroposterior X-ray view, the diagnostic criteria is the misalignment of
the medial edge of the second metatarsal with the medial edge of the intermediate
cuneiform and a distance of > 2 mm between the base of the first and second metatarsals
or between the first cuneiform and the base of the second metatarsal. Sometimes, the
pathognomonic Fleck sign is observed, which is a bone fragment from the base of the
second metatarsal avulsed due to traction of the Lisfranc ligament, located in the
intermetatarsal space.[6] In the lateral view, the dorsal and plantar edges of the metatarsals should align
with the edges of the cuboid and cuneiform bones; any misalignment is abnormal.[6] In the 30-degree oblique view, the medial edge of the lateral cuneiform should align
with the medial edge of the base of the third metatarsal, and the medial edge of the
cuboid should align with the medial edge of the fourth metatarsal.[8] Despite the various incidences and radiographic signs, the diagnostic accuracy of
this method is low.[8] In patients whose radiography is negative but there is clinical suspicion, stress
radiography, computed tomography or magnetic resonance imaging should be performed.[9] In both cases herein presented, radiographic signs such as the Fleck sign and misalignment
between the metatarsals and cuneiforms were observed, making the diagnosis evident
through this imaging method.
Stress radiography can be performed under anesthesia, and it involves applying maneuvers
under fluoroscopy, enabling the dynamic evaluation of the foot. These maneuvers consist
of pressing the midfoot, pronation, supination, abduction, adduction, and moving the
first metatarsal in the dorsal and plantar directions.[9] Cadaveric studies[9] have found that the abduction stress maneuver was superior to weight-bearing radiography
for the diagnosis of Lisfranc instability.
The gold standard is computed tomography, particularly with high-velocity trauma,
as it provides insight into fracture pattern, displacement, comminution, and surgical
planning.[5] It identifies an additional 51% of tarsal bone fractures and 38% of metatarsal bone
fractures.[10] The disadvantage is that the tomography is not load-bearing and dynamic; therefore,
it less useful to diagnose subtle injuries (pure ligamentous).[8] Magnetic resonance imaging is not routinely used but can aid in the diagnosis of
ligamentous injury in the absence of bone injury, occult fractures, or edema.[5] In the first case herein presented, a computed tomography scan was requested after
the placement of Kirschner wires to assess displacement, comminution, and mainly to
plan the definitive surgery.
Many classification schemes have been described, such as those by Hardcastle and Myerson
(total, partial, and divergent incongruence), Quenu and Kuss (homolateral, isolated,
divergent), and Nunley and Vertullo (severity combining clinical assessment, weight-bearing
radiographs, and bone scintigraphy). It is worth mentioning that none of these classifications
reliably correlates with prognosis and treatment, having very limited usefulness in
clinical practice.[7]
[11]
The goal in treating these injuries is to achieve a stable, pain-free plantigrade
foot, which requires an anatomical reduction of the Lisfranc complex.[8] For Lisfranc injuries without evidence of instability, such as nondisplaced fractures
or those with a diastasis shorter than 2 mm and absence of arch collapse confirmed
by weight-bearing and stress radiographs, immobilization with a below-knee cast is
recommended for 6 to 12 weeks.[7] In addition to the cast or immobilizing boot, the recommendation is not to bear
weight for 1 or 2 weeks. If, by the second or third weeks, after a reduction in swelling
and pain in the foot, a weight-bearing X-ray shows stability, controlled weight-bearing
may begin. At 6 weeks, the boot may be removed, and a firm orthopedic arch support
may be prescribed. Exercise can begin in the third month and return to sports is possible
at 6 to 8 months. However, if the injury is displaced, surgical treatment is advisable
to prevent complications such as midfoot arthritis or further displacement.[7] To date, there is no consensus regarding surgical treatment; no surgical technique
is superior to another. If the displacement is severe or there is a complex dislocation,
the suggestion is to perform closed reduction and immobilization under sedation to
improve symptoms, recover alignment, and reduce vascular risk. If the reduction cannot
be maintained, the provisional use of Kirschner wires is suggested. After the soft
tissue edema improves, definitive surgery will be scheduled, and the recommendation
is that it be performed in the first 6 weeks, with the prognosis being worse after
this time, requiring arthrodesis in most cases.[7] The more time passes after the initial injury, the more difficult it will be to
obtain a satisfactory reduction of displaced or dislocated fractures.[8] Compartment syndrome, which is common in this pathology, is another reason for early
surgical intervention. In the first case herein presented, provisional fixation with
Kirschner wires was performed early, and definitive surgery, 20 days after the accident,
an adequate time according to the literature[8], which positively influences the prognosis of the injury.
In the young athletic population, as there is high demand to restore function as much
as possible, it is necessary to maintain movement in the medial column. Arthrodesis
in this group of patients, apart from limiting mobility, can place excessive load
on adjacent structures, predisposing to nonunion, stress fractures, or the development
of metatarsalgia due to transfer.[3] Avoid arthrodesis in pediatric patients with open physis.[8]
Fixation with screws above the Kirschner wires is recommended for the medial and intermediate
columns, specifically between the first cuneiform and the first metatarsal, and between
the second cuneiform and the second metatarsal. It is important to fixate between
the medial cuneiform and the second metatarsal, which recreates the Lisfranc ligament.[7] Lewis and Anderson[19] popularized the “home run” screw and intercuneiform screws. “Home run” consists
of using a 3.5-mm or 4-mm cortical screw under the principle of interfragmentary compression
following the course of the Lisfranc ligament. By adding intercuneiform screws to
the screw already described, it would be possible to reduce the medial column to the
intermediate column.[8] The techniques to replace the Lisfranc ligament have evolved, ranging from partially-threaded
cannulated screws of 4.0 mm to 5.0 mm to headless compression screws. Hansen[18] proposed that both the medial and intermediate columns contain non-essential joints
and could be fused with permanent implants. Conversely, in the lateral column, the
opposite occurs, needing reconstruction and preservation of the joint. This is typically
achieved by temporarily fixing and maintaining reduction of this column using Kirschner
wires, which are usually removed around 6 weeks on average.[8] Recently, the button has emerged as an alternative to the “home run” screw as a
replacement for the Lisfranc ligament, having the advantage of maintaining the flexibility
of the midfoot, without losing stability.[12] In the first case herein presented, a headless compression screw was used between
the medial and intermediate cuneiforms, with locking plates for the first three tarsometatarsal
joints, another headless compression screw for the fourth joint, and a Kirschner wire
for the last joint. Additionally, a button was employed to simulate the Lisfranc ligament,
a configuration little described in the literature but, as we will see, yielding favorable
outcomes. In the second case herein reported, Kirschner wires were used as definitive
treatment, also resulting in favorable outcomes. Comparing the results of both cases
is not feasible due to the greater severity involved in the first case (involvement
of more joints).
The use of plates with screws represents an alternative to transarticular screws.
This method of fixation likely provides greater rigidity and less displacement compared
to transarticular screw fixation.[13] Ardoin and Anderson[14] recommend using locked screws in the most distal and proximal holes, while in those
closest to the joint, non-locked screws, in order to direct them away from it if necessary,
a recommendation that was followed in the first case herein presented.
Primary arthrodesis is suggested for highly displaced and comminuted fracture dislocations,
in which there is extensive joint damage that makes the onset of posttraumatic osteoarthritis
inevitable.[8]
Regarding the approach, both were dorsal. On the one hand, a double dorsal incision
can be made, in which they are separated by a skin bridge of 4 to 5 cm.[8] On the other hand, a simple modified dorsal approach can be performed to access
all three columns, which has a complication rate comparable to that of double incision,
but greater exposure.[8] In the first case herein reported, a single dorsal approach was performed, while
in the second case, a double dorsal incision was used, with neither case experiencing
complications.
Patients who undergo surgery are advised not to bear weight for 6 weeks. They require
a custom-molded shoe for up to 6 months. Physical therapy should begin in the early
postoperative period. Removal of hardware, such as Kirschner wires, is typically performed
around 6 weeks, whereas plates and screws may be removed between the fourth and sixth
months. It is recommended to remove only transarticular screws from the tarsometatarsal
joints, while leaving the Lisfranc and intercuneiform screws in place to prevent diastasis
later on.[8]
The prognosis depends on the anatomical reduction achieved during surgery and the
extent of articular surface damage. It is important to emphasize that the quality
of anatomical reduction translates into restoring the length of the medial and lateral
columns as well as the shape of the longitudinal arch. This is a crucial factor to
predict functional outcomes, often more significant than the choice of fixation material.
It should be noted that patients treated with Kirschner wires have a higher risk of
fixation loss compared to those submitted to rigid fixation with plates and screws
(37.5% versus 0%). The prognosis worsens with the delay in diagnosis, which is often
the case with subtle Lisfranc injuries that can go unnoticed.[8] Displacement greater than 2 mm and poor reduction are associated with symptomatic
and radiographic arthritis.[7] The two patients herein presented had very acceptable scores in the various validated
scores, which reflects good functionality and quality of life after the surgical interventions
performed.
