SPORT LISFRANC JOINT INJURIES

Thomas StaysniakDPM

19th Annual Primary Care & Orthopaedic & Sports Medicine Symposium

NO DISCLOSURES

Jacques Lisfranc (1790-1847) field surgeon in Napoleon’s army.

Described an amputation through the tarsometatarsal articulation of the foot secondary to gangrene that developed after injury when a soldier fell off a horse with their foot still engaged in the stirrup.

LISFRANC JOINT

Lisfranc’s joint commonly describes the tarsometatarsal joint.

Lisfranc’s ligament describes the ligamentous attachments of the second metatarsal base to the medial cuneiform.

Dorsal Lisfranc’s Joint Ligaments

Transverse ligaments join all the metatarsal bases except the first and second.

Plantar Lisfranc’s Joint Ligaments Soft tissue support along the plantar foot is

extensive and abundant but relatively sparse along the dorsal surface leaving it weaker and more vulnerable to injury.

The second metatarsal is the “keystone” to the Lisfranc’s joint.

Mechanisms of Lisfranc Injuries

Commonly described as an injury occurring with the ankle and foot in a fixed or locked in plantarflexion.

Axial load drives the metatarsal base regions dorsally through the weaker area of the Lisfranc’s joint.

Axial loading mechanisims on a plantarflexed foot

Sports Lisfranc Injury Mechanism

Not mediated by contact or axial loading. Subtle twisting injury with the forefoot

abducted on the rearfoot. Purely ligamentous injury.

Foot Ankle Int. 2018 Oct Injury Pattern in Ligamentous Lisfranc Injuries in Competitive Athletes.Porter DA1, Barnes AF1, Rund A1, Walrod MT1.METHODS: Eighty-two patients (64 males, 18 females) sustained an unstable Lisfranc injury (49 left, 33 right) and met inclusion criteria.Injuries were classified as traditional dislocation (TRAD, first to second TMT ligament tear), medial column dislocation (MCD, second TMT, and medial-middle cuneiform ligament tear), or proximal extension dislocation (PE, first, second, and medial-middle cuneiform ligament tear) and the injury pattern confirmed at surgery. All athletes underwent open reduction with internal fixation (ORIF) of each unstable midfoot segment. Fisher exact tests and 2-tailed t tests were used to analyze statistical significance according to injury pattern, sport, gender difference, hindfoot angle alignment, and injured side ( P < .05).RESULTS: Average age of athletes was 21.0 ± 5.3 years old (range 12-40), and return to sports was 7.5 ± 2.1 months. Injury distribution was as follows: TRAD (n = 40), MCD (n = 17), and PE (n = 23). MCD trended toward a longer return to sport (8.4 ± 3.3 months, P = .074). Football was the most common sport at time of injury (n = 48). Wakeboard athletes (n = 5) were older (31.4 ± 3.2, P = .0002), and MCD tears were more prevalent among them ( P = .061). Basketball (n = 13) players were significantly younger (19.1 ± 2.5 years, P = .028) and returned to sports quicker (5.2 ± 0.7, P = .0002). Return to sport data indicated a typical population for athletes with Lisfranc injury in these sports.CONCLUSION: Proximal extension disruption (intercuneiform ligament tear) occurred in 50% of these low-energy Lisfranc athletic injuries. MCDand PE may be more prevalent than previously understood. This is the first study to document the extent, pattern, and prevalence of associated intercuneiform ligament tears in the competitive athlete with a low-energy subtle, unstable Lisfranc injury.LEVEL OF EVIDENCE: Level IV, retrospective case series.

https://www.ncbi.nlm.nih.gov/pubmed/30345792https://www.ncbi.nlm.nih.gov/pubmed/?term=Porter%20DA%5BAuthor%5D&cauthor=true&cauthor_uid=30345792https://www.ncbi.nlm.nih.gov/pubmed/?term=Barnes%20AF%5BAuthor%5D&cauthor=true&cauthor_uid=30345792https://www.ncbi.nlm.nih.gov/pubmed/?term=Rund%20A%5BAuthor%5D&cauthor=true&cauthor_uid=30345792https://www.ncbi.nlm.nih.gov/pubmed/?term=Walrod%20MT%5BAuthor%5D&cauthor=true&cauthor_uid=30345792

Pain Swelling Bruising Deformity Inability to pushoff

Clinical Signs

X-RayFindings

AP – 1st and 2nd tarsometatarsal joints, medial and intermediate cuneiform joints, naviculocuneiform joints (“fleck sign”, joint incongruity, additional fractures of navicular, toes, and metatarsals).

Oblique – 2nd, 3rd, 4th, and 5th tarsometatarsal joints (joint congruity and associated fractures especially of the cuboid).

Lateral – 1st and 2nd tarsometatarsal joints, cuboid, and navicular.

AP

OBLIQUE

LATERAL

CT SCANMore useful with delayed presentation,

extensive injury and reconstructive planning.

MRI is very useful in subtle injuries

49-year-old female for evaluation of generalized pain in the right foot after falling in her bedroom???

Probe is able to easy placed through Lisfranc ligament but not the intercuneiform joint. 1stand 3rd tarsometatarsal joints are unstable.

Post op SPORT (purely ligamentous) Lisfranc Injury

Non-weight bearing splint 2weeks

Non-weight bearing in removable cast 4-6 weeks with removable cast

Can start off weight bearing ROM, pool therapy after two weeks

Partial weight bearing in removable cast for an additional 6 weeks with arch support

Gradual transition to shoes and activity after about 12 weeks

May need hardware removal 4-6 months (12 months in non-athlete and if symptomatic)

Return to practice 12-16weeks

Nunley (The Event 2014) Anderson (Alabama OrthopedicSociety)

Foot Ankle Int. 2018 Jul;39(7):801-807. Return to Sports and Physical Activities After Open Reduction and Internal Fixation of Lisfranc Injuries in Recreational Athletes.Mora AD1, Kao M1, Alfred T1, Shein G1, Ling J1, Lunz D1.Author informationRESULTS: Postoperatively, 31 patients (94%) were able to return to some form of sport. Twenty-two patients (66%) returned to playing sport at or above their preinjury level. Of the 11 patients who played less sport, 6 had ongoing pain, and the remaining 5 were asymptomatic but were participating less frequently because of other lifestyle reasons. In addition, of the 33 patients, 11 (33%) had some degree of ongoing pain that might limit their ability to return to sports and physical activities. There was strong correlation between overall FAOS and the Sports Questionnaire.CONCLUSION: Most patients who sustained a Lisfranc injury could return to sport and physical activity after ORIF. Patients should be counseled preoperatively that about 1 in 3 might experience continued pain at the injury site Level IV, retrospective case series.

https://www.ncbi.nlm.nih.gov/pubmed/29606024https://www.ncbi.nlm.nih.gov/pubmed/?term=Mora%20AD%5BAuthor%5D&cauthor=true&cauthor_uid=29606024https://www.ncbi.nlm.nih.gov/pubmed/?term=Kao%20M%5BAuthor%5D&cauthor=true&cauthor_uid=29606024https://www.ncbi.nlm.nih.gov/pubmed/?term=Alfred%20T%5BAuthor%5D&cauthor=true&cauthor_uid=29606024https://www.ncbi.nlm.nih.gov/pubmed/?term=Shein%20G%5BAuthor%5D&cauthor=true&cauthor_uid=29606024https://www.ncbi.nlm.nih.gov/pubmed/?term=Ling%20J%5BAuthor%5D&cauthor=true&cauthor_uid=29606024https://www.ncbi.nlm.nih.gov/pubmed/?term=Lunz%20D%5BAuthor%5D&cauthor=true&cauthor_uid=29606024https://www.ncbi.nlm.nih.gov/pubmed/29606024

Foot Ankle Int. 2016 Apr;37(4):355-62. Return to Sports and Physical Activities After Primary Partial Arthrodesis for Lisfranc Injuries in Young Patients.MacMahon A1, Kim P1, Levine DS1, Burket J2, Roberts MM1, Drakos MC1, Deland JT1, Elliott AJ1, Ellis SJ3.Author informationRESULTS: Patients participated in 29 different and 155 total physical activities preoperatively, and 27 different and 145 total physical activities postoperatively. Preoperatively, 47.1% were high impact, and postoperatively, 44.8% were high impact. The most common activities were walking, bicycling, running, and weightlifting. Compared to preoperatively, difficulty was the same in 66% and increased in 34% of physical activities. Participation levels were improved in 11%, the same in 64%, and impaired in 25% of physical activities. Patients spent on average 4.2 (range, 0.0 to 19.8) hours per week exercising postoperatively. In regard to return to physical activity, 97% of respondents were satisfied with their operative outcome. Mean postoperative FAOS subscores were significantly worse for patients who had increased physical activity difficulty.CONCLUSION: Most patients were able to return to their previous physical activities following primary partial arthrodesis for a Lisfranc injury, many of which were high-impact. However, the decreased participation or increase in difficulty of some activities suggests that some patients experienced postoperative limitations in exercise. Future studies could compare sports outcomes between primary partial arthrodesis and open reduction internal fixation for Lisfranc injuries.LEVEL OF EVIDENCE: Level IV, retrospective case series.

https://www.ncbi.nlm.nih.gov/pubmed/26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=MacMahon%20A%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Kim%20P%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Levine%20DS%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Burket%20J%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Roberts%20MM%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Drakos%20MC%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Deland%20JT%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Elliott%20AJ%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/?term=Ellis%20SJ%5BAuthor%5D&cauthor=true&cauthor_uid=26596795https://www.ncbi.nlm.nih.gov/pubmed/26596795

Aofie MacMahon, BA, Paul Kim, MD, David S. Levine, MD, Jayme Burket, PhD, Matthew M. Roberts, MD, Mark C. Drakos, MD, Jonathon T. Deland, MD, Andrew Elliot, MD, and Scott J. Ellis, MD

Chart1

Increased

Same

Impaired

38 patients

Return to Sports and Physical Activities After Primary Partial Arthrodesis for Lisfranc Injuries in Young Patients

0.11

0.64

0.25

Sheet1

Return to Sports and Physical Activities After Primary Partial Arthrodesis for Lisfranc Injuries in Young Patients

Increased11%

Same64%

Impaired25%

4th Qtr1.2

To resize chart data range, drag lower right corner of range.

Orthop J Sports Med. 2015 Jul; 3(7 suppl2):

PMCID: PMC4901597Outcomes of Lisfranc Injuries in the National Football League

Kevin Jude McHale, MD,1 Joshua Rozell, MD,1 Andrew Milby, MD,1 James L. Carey, MD, MPH,2 and Brian J. Sennett, MD2

Author information Copyright and License information Disclaimer

Data on National Football League (NFL) players who sustained a Lisfranc injury during a ten-year time period (2000-2010). Variables included age, experience, position, and operative vs. non-operative management.

28 NFL athletes in the study period, including 11 offensive players and 17 defensive players.

While 2 of 28 (7.1%) players never returned to the NFL, the remaining 26 (92.9%) athletes returned to competition at a median 11.1 months from time of injury. Players treated non-operatively

were noted to have an earlier return to play.

Analysis of pre- and post-injury athletic performance revealed no statistically significant changes following return to sport after Lisfranc injury. Conclusion:

Greater than 90% of NFL athletes who sustained Lisfranc injuries returned to play in the NFL at a median 11.1 months from time of injury. Operative treatment was associated with a longer time to return; however, this is a potential surrogate for greater injury severity. Offensive and defensive players experienced a decrease in performance after return from injury that did not reach statistical significance when compared to their respective control groups over a similar time period.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4901597/https://www.ncbi.nlm.nih.gov/pubmed/?term=McHale%20KJ%5BAuthor%5Dhttps://www.ncbi.nlm.nih.gov/pubmed/?term=Rozell%20J%5BAuthor%5Dhttps://www.ncbi.nlm.nih.gov/pubmed/?term=Milby%20A%5BAuthor%5Dhttps://www.ncbi.nlm.nih.gov/pubmed/?term=Carey%20JL%5BAuthor%5Dhttps://www.ncbi.nlm.nih.gov/pubmed/?term=Sennett%20BJ%5BAuthor%5Dhttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC4901597/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4901597/https://www.ncbi.nlm.nih.gov/pmc/about/disclaimer/

SUMMARY

Sport Lisfranc Mechanism with increasing incidence.

Missed diagnosis could result in significant disability.

Weight bearing x-rays bilateral.MRI helpful if in question.Surgery does not always equate

to complete pain relief and return to activity.

SPORT LISFRANC JOINT INJURIESSlide Number 2Slide Number 3Slide Number 4Slide Number 5Dorsal Lisfranc’s Joint LigamentsSlide Number 7Slide Number 8Slide Number 9Mechanisms of Lisfranc InjuriesSlide Number 11Slide Number 12Slide Number 13Slide Number 14Slide Number 15Slide Number 16Clinical SignsX-Ray FindingsSlide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Slide Number 25Slide Number 26Slide Number 27Slide Number 28Slide Number 29Slide Number 30Post op SPORT (purely ligamentous) Lisfranc InjurySlide Number 32Slide Number 33Slide Number 34Slide Number 35Slide Number 36