Abstract
Background:
Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal (TMT) joint complex from ligamentous sprains to fractures with dislocation. While studies have shown it is possible to return to sport (RTS) after low-energy injuries, no literature exists demonstrating RTS after homolateral fracture/dislocation of all 5 metatarsals.
Indications:
We present a novel technique for repair of homolateral Lisfranc fracture/dislocation of metatarsals 1-5 which may be used in high-level athletes attempting to return to competition.
Technique Description:
A dual approach is utilized, with a dorsal approach to allow for fusion of the 2nd and 3rd TMT joints and medial approach for internal bracing of the 1st TMT joint. The 2nd and 3rd metatarsals were denuded of all cartilage and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites and then stability of the 1st TMT was reassessed. A guidewire for the cannulated InternalBrace (Arthrex; Naples, FL) system is initially inserted into the base of the 1st metatarsal. Positioning is confirmed with fluoroscopic imaging and the 3.4 mm drill is passed over the wire, followed by the cannulated tap. A 4.75 mm SwiveLock anchor (Arthrex; Naples, FL) with FiberTape suture (Arthrex; Naples, FL) is then inserted into the metatarsal base. The guidewire is placed in a reciprocating position on the medial cuneiform. The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap. A 3.5 mm SwiveLock anchor is then loaded with the FiberTape suture from the 1st metatarsal. Tensioning is performed, and the 3.5 mm SwiveLock anchor is inserted into the medial cuneiform.
Results:
The athlete was cleared to return to full competition 9 months following surgery. Physical examination demonstrated stability in dorsiflexion and abduction. Both weight-bearing x-rays and computed tomography scans showed no evidence of hardware failure, no instability of the 1st TMT joint, and solid fusion of the 2nd and 3rd TMT joints.
Discussion/Conclusion:
Current literature demonstrates that RTS is possible for athletes suffering from low-energy Lisfranc injuries. This novel surgical technique is the first to demonstrate return to sport of a high-level athlete from homolateral fracture/dislocation of all 5 metatarsals.
This is a visual representation of the abstract.
Video Transcript
In this video, we describe a case report of a homolateral Lisfranc fracture/dislocation of the 1st-5th metatarsals in a collegiate quarterback.
These are our disclosures.
Lisfranc injuries encompass a spectrum of injuries to the tarsometatarsal joint complex from partial tears of the ligamentous structures to full tear with diastasis.8,10 Injury may also result in fracture of the distal tarsal or metatarsal bones, most commonly at the base of the 2nd metatarsal.8,10 Trauma is the primary mechanism of injury, classically due to an axial force on a plantarflexed foot. 10 High-energy trauma may result in dislocation of 1 or more metatarsals. 6 Homolateral dislocation involves lateral displacement of all 5 metatarsals with or without fracture of the 2nd metatarsal base. 6 Lisfranc injuries occur rarely in the general population but are significantly higher in American football players, as 4% of collegiate players experience this injury. 5
Nunley and Vertullo 8 developed a classification system for purely ligamentous injuries of the tarsometatarsal (TMT) joint based on degree of diastasis between 1st and 2nd metatarsal and presence of arch height loss.
The Myerson classification system describes more complex injuries to the TMT joint. 6
In type A injuries, the TMT joint complex is totally incongruent with lateral or dorsoplantar dislocation of all 5 metatarsals. Type B injuries are partially incongruent, and type C are divergent injuries.
We present a case report of a 22-year-old Division 1 collegiate quarterback who presented after injury during an in-game tackle. He had pain and swelling of his left midfoot as well as laxity in dorsiflexion and abduction of the midfoot.
In this video, you can see the classic mechanism of injury with axial force on a plantarflexed left ankle.
Initial injury films presented here showing a homolateral Lisfranc fracture dislocation involving all 5 rays. This was an isolated injury without neurovascular injury but with threatened medial skin.
Initial closed reduction was performed to reduce pressure on the skin and allow for swelling to improve before surgery. Computed tomography (CT) scan was obtained to further delineate the fracture pattern and for surgical planning.
Preoperative CT imaging shows significant comminution at the plantar aspect of the base of the second metatarsal. The CT scan also demonstrates no fractures involving the 1st TMT joint.
Due to the comminution of the second metatarsal base in an otherwise purely ligamentous injury, the decision was made to fuse the 2nd and 3rd TMT joints to provide stability of the middle column, but several different surgical options for the 1st TMT joint were discussed.
Treatment options for this injury pattern, especially in a young, active patient, is quite controversial. Many surgeons would suggest that fusion of the 1st to 3rd TMT joints is the most appropriate option for this patient based on outcome studies comparing fusion with open reduction internal fixation (ORIF).2,4
Fusion would provide reliable stability with only one surgery, but at the cost of physiologic motion, mainly in the 1st TMT joint.
ORIF of the 1st TMT joint is a viable option to allow for joint preservation but would require hardware removal to restore motion.
The use of a flexible suture fixation of the 1st TMT joint allows for preservation of motion while fusion of the middle column provides stability to the midfoot.
A thorough discussion with the patient is necessary before all surgical procedures, and the patient ultimately decided to proceed with InternalBrace (Arthrex; Naples, FL) reconstruction of the 1st TMT joint.
Once the patient's soft tissue was amenable to surgical fixation, the patient was taken to the operating room. Regional anesthesia with monitored anesthesia care (MAC) was utilized. Patient was positioned supine with the leg elevated to facilitate lateral fluoroscopy. A tourniquet was not utilized so that adequate hemostasis could be achieved during the approach, but this is strictly surgeon preference.
A dual approach is utilized, with a medial approach to the 1st TMT joint and 1 dorsal approach to the 2nd and 3rd TMT joints.
Care must be taken to maintain an adequate skin bridge and both incisions should be made prior to any fixation in order to fully characterize the instability pattern, as well as confirm anatomic reduction of all joints.
A standard medial approach to the 1st TMT joint is utilized. The medial approach is necessary to provide enough plantar exposure for placement of the InternalBrace. Caremust be taken to avoid injury to the anterior tibial tendon, which ultimately limits the plantar and proximal exposure.
This is an intraoperative video of the 1st TMT joint through a medial approach prior to any fixation. Note the complete instability of the joint, with instability in both the sagittal plane as well as abduction. The articular cartilage is also thoroughly inspected to ensure that there is no significant chondral injury that would preclude a joint sparing procedure, and the patient was made aware preoperatively that a large chondral injury could force us to proceed with fusion of the 1st TMT joint.
A standard dorsal incision is utilized for fusion of the 2nd and 3rd TMT joints, taking care to avoid injury to any branches of the superficial peroneal nerve.
With both incisions made, initial temporary fixation is obtained, ensuring that all 5 TMT joints are anatomically reduced. The 2nd and 3rd TMT joints were denuded of all cartilage and the fusion site was fully prepared. Rigid fixation was applied to the fusion sites and then stability of the 1st TMT was reassessed.
After rigid fixation of the 2nd and 3rd TMT fusion sites, the stability of the 1st TMT joint was again tested. This video demonstrates that there is no longer abduction instability, but there is still significant sagittal plane instability. The InternalBrace system was then utilized to stabilize the 1st TMT joint.
A guidewire for the cannulated InternalBrace system is initially inserted into the base of the 1st metatarsal, approximately 1 cm from the articular surface and within the plantar 1/3 of the metatarsal.
Positioning is confirmed with fluoroscopic imaging, and the 3.4 mm drill is passed over the wire, followed by the cannulated tap.
A 4.75 mm SwiveLock anchor (Arthrex; Naples, FL) with FiberTape suture (Arthrex; Naples, FL) is then inserted into the metatarsal base in standard fashion.
The guidewire is then placed in a reciprocating position on the medial cuneiform, again placing it 1 cm proximal to the TMT joint and as plantarly as exposure will allow without compromising the anterior tibial tendon insertion.
The 2.7 mm drill is passed over the wire, followed by the 3.5 mm tap.
A 3.5 mm SwiveLock is then loaded with the FiberTape from the 1st metatarsal.
Tensioning is performed, holding the great toe in dorsiflexion to plantarflex the first metatarsal and visually ensuring that the 1st TMT joint is reduced.
The suture is marked in standard fashion to identify appropriate tensioning, and the 3.5 mm SwiveLock is inserted into the medial cuneiform.
Intraoperative photos are shown here demonstrating the technique.
Photos 1 and 2 demonstration insertion of the 4.75 mm SwiveLock anchor with FiberTape into the base of the 1st metatarsal.
Photos 3 and 4 demonstrate anchoring the FiberTape into the medial cuneiform with a 3.5 mm SwiveLock.
The stability of the 1st TMT joint is then reassessed. This video demonstrates the completed construct with Internal Brace reconstruction of the 1st TMT joint. Notice that sagittal plane instability is gone, and there is stability in all planes.
Following surgery, the patient was placed in a splint and was non-weight-bearing for the first 2 weeks. He was then non-weight-bearing in a boot for 4 weeks with encouraged range of motion followed by 6 weeks of weight-bearing as tolerated in the boot. After 12 weeks, he was transitioned back to normal footwear as he proceeded with physical therapy.
The athlete was cleared to return to full competition 9 months following surgery. Physical examination demonstrated stability in both dorsiflexion and abduction. Weight-bearing x-rays showed no evidence of hardware failure and no evidence of any instability of the 1st TMT joint. CT scan 9 months from surgery demonstrates solid fusion of the 2nd and 3rd TMT joints as well as maintained anatomic reduction of the 1st TMT joint.
These videos taken 9 months postoperative demonstrate stability in straight line sprints and cutting at 45-degree angles as well as the ability to perform noncontact quarterback drills.
While randomized clinical studies regarding internal bracing techniques for Lisfranc injuries are lacking, a recent study using 24 cadaveric models comparing suture augmented ligamentplasty with conventional transarticular screws showed equivalent stability with suture augmentation exhibiting less variability. 7
Current literature focuses on athletes with low-energy ligamentous injuries or fractures.1-4,9 This is the first case of homolateral fracture/dislocation in a Division 1 varsity athlete successfully returning to sport.
Meyer et al 5 investigated nonoperative management of stage 1 and 2 ligamentous injury in 24 American collegiate football players. Athletes demonstrated a 100% return to sport (RTS) rate, at a mean time of 2 weeks.
Nunley and Vertullo 8 also described 7 stage 1 and 8 stage 2 ligamentous injuries managed in three different ways. All yielded 100% return to sport at a mean time of 15.2 weeks.
Bleazey et al 1 detailed 13 Myerson type B2 fractures treated with percutaneous reduction internal fixation with 100% RTS rate at a mean of 16.6 weeks. While also fractures, these injuries represent a very different, lower-energy injury pattern compared with our case report.
Deol et al 3 investigated Lisfranc injuries in professional soccer and rugby players. This study investigated 17 athletes, 7 stage 2 ligament injuries, 6 type B fractures, and 4 type C fractures with ORIF or primary partial arthrodesis. Sixteen of 17 athletes successfully returned to competition at a mean of 20.1 weeks.
Robertson et al 9 performed a systematic review and meta-analysis comprising 17 studies with a total of 366 patients investigating RTS following Lisfranc injuries. 9 Nonoperative management of stage 1 injuries (n = 35) had a return rate (RR) of 100%, at a mean 4.0 weeks, stage 2 injuries (n = 16) also had 100% return rate but at 9.1 weeks. Percutaneous reduction internal fixation (n = 42) is only possible in low-energy injuries but showed better return rate and return time (98% RR, 11.6 weeks RT) compared with open reduction internal fixation (n = 139, RR 78%, RT 19.6 weeks) and primary partial arthrodesis (n = 85, RR 85%, RT 22.0 weeks).
RTS was also evaluated based on type of injury. Stage 1 ligamentous injuries (n = 35) had a 100% return rate at mean 4 weeks. Stage 2 injuries (n = 32) return rate decreased slightly to 97% at 13.3 weeks. Stage 3 (n = 6) injuries were slightly lower still at 83% return to sport at mean 15.5 weeks. 9 Fracture injuries were also evaluated. Myerson type B fractures with partial incongruity of the TMT joint (n = 23) returned to sport 100% of the time with mean time to return of 18.3 weeks. Divergent type C injuries (n = 4) also reported 100% return to sport but at 20.5 weeks. 9
The literature demonstrates that return to sport is possible for athletes with Lisfranc injuries though the data focuses on either pure ligamentous injury or type B and C fractures. This study demonstrates a novel surgical approach to homolateral fracture/dislocation. While return to sport in this athlete took longer than previous studies of lower-energy injuries, it is possible for athletes with homolateral displacement to return to full competition.
This concludes our case report of homolateral Lisfranc fracture/dislocation of 1st-5th metatarsals in a division 1 collegiate quarterback.
Thank you.
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: A.R.K. receives IP royalties from Acumed LLC, Biomedical Enterprises, and DePuy; is a paid consultant for Arthrex Inc; and receives publishing royalties from Elsevier and LWW. V.K.T is a paid consultant for Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Author Contributions
Writers: Steven R. Dayton; Kurt M. Krautman; Narrators: Steven R Dayton; Kurt M Krautman; Instructional Design & Development: Michael J. Boctor; Steven R Dayton; Kurt M Krautman; Vehniah K. Tjong; Anish R. Kadakia.
Ethical Statements
All authors have significantly contributed to manuscript and video production, and all authors agreed to author order and submission. The manuscript and video have not been submitted elsewhere and will not be until the editorial process is complete. No previously published content was utilized. Informed photographic consent was obtained from patient actors. No funding sources were utilized, and relevant disclosures are listed in the disclosures slide.
