Introduction. Lisfranc joint injuries are increasingly recognised in elite soccer and rugby players. Currently no evidence-based guidelines exist on timeframes for return to training and competition following surgical treatment. This study aimed to see whether return to full competition following surgery for Lisfranc injuries was possible in these groups and to assess times to training, playing and possible related factors. Material/Methods. Over 46-months, a consecutive series of fifteen professional soccer (6) and rugby(9) players in the English Premierships/Championship, was assessed using prospectively collected data. All were isolated injuries, sustained during competitive matches. Each had clinical and radiological evidence of injury and was treated surgically within thirty-one days. A standardised postoperative regime was used. Results. Follow-up was obtained in all fifteen cases. Eight cases were ligamentous injuries and seven were bony. Time from injury to fixation ranged from 10–31 days. One athlete retired following a ligamentous injury. All remaining fourteen returned to training and full competition. Excluding the retired case, mean return to training time was 20.2 weeks and to full competition was 25.6 weeks. No significant difference existed between the mean return to competition time for rugby (27.8 weeks) and soccer(24.7 weeks). A significant difference existed between the mean return to competition time for ligamentous (23.7 weeks) compared to bony(27.6 weeks) injuries(p = 0.012). Three patients suffered deep peroneal nerve sensation loss, two of which fully recovered. Discussion/Conclusion. Return to competitive elite-level soccer and rugby is possible following surgically treated Lisfranc injuries. Return to training can take up to 24 weeks and playing up to 31 weeks, with bony injuries taking longer. To our knowledge this is the largest series of its kind and whilst we recognise it contains small numbers, we feel it provides some guidance on rehabilitative timeframes for those who treat and those who sustain these injuries. Evidence Level: 4

Injuries to the foot in athletes are often subtle and can lead to a substantial loss of function if not diagnosed and treated appropriately. For these injuries in general, even after a diagnosis is made, treatment options are controversial and become even more so in high level athletes where limiting the time away from training and competition is a significant consideration.

In this review, we cover some of the common and important sporting injuries affecting the foot including updates on their management and outcomes.

Cite this article: Bone Joint J 2016;98-B:1299–1311.

Background. Undisplaced Lisfranc-type injuries are subtle but potentially unstable fracture-dislocations with little known about the natural history. These injuries are often initially managed conservatively due to lack of initial displacement and uncertainty regarding subsequent instability at the tarsometatarsal joints (TMTJ). The aim of this study was to determine the secondary displacement rate and the need for delayed operative intervention in undisplaced Lisfranc injuries that were managed conservatively at initial presentation. Methods. Over a 6-year period (2011 to 2017), we identified 24 consecutive patients presenting to a university teaching hospital with a diagnosis of an undisplaced Lisfranc-type injury that was initially managed conservatively. Pre-operative radiographs were reviewed to confirm the undisplaced nature of the injury (defined as a diastasis< 2mm at the second TMTJ). The presence of a ‘fleck’ sign (small bony avulsion of the second metatarsal) was also noted. Electronic patient records and sequential imaging (plain radiographs/CT/MRI) were scrutinized for demographics, mechanism of injury and eventual outcome. Results. The mean age of the patients at the time of injury was 42 years (19 Female). 96% (23/24) were low energy injuries and 88% (21/24) had a positive ‘fleck sign’. The secondary displacement rate in this group of patients was 62.5% (15/24) over a median interval of 14 days (range 0 to 482 days). 12 patients underwent open reduction internal fixation after a median interval of 29 days (range 1 to 294 days) from their initial injury. One patient required TMTJ fusion at 19 months and two patients were managed non-operatively. The injury remained undisplaced in 37.5% patients (9/24) with only one patient requiring subsequent TMTJ fusion at 5 months. Conclusion. Undisplaced Lisfranc injuries have a high rate of secondary displacement and warrant close follow-up. Early primary stabilisation of undisplaced Lisfranc injuries should be considered to prevent unnecessary delays in surgical treatment

Background. Anatomical reduction of unstable Lisfranc injuries is crucial. Evidence as to the best methods of surgical stabilization remains sparse, with small patient numbers a particular issue. Dorsal bridge plating offers rigid stability and joint preservation. The primary aim of this study was to assess the medium-term functional outcomes for patients treated with this technique at our centre. Additionally, we review for risk factors that influence outcomes. Methods. 85 patients who underwent open reduction and dorsal bridge plate fixation of unstable Lisfranc injuries between January 2014 and January 2019 were identified. Metalwork was not routinely removed. A retrospective review of case notes was conducted. The Manchester-Oxford Foot Questionnaire summary index (MOXFQ-Index) was the primary outcome measure, collected at final follow-up, with a minimum follow-up of 24 months. The American Orthopedic Foot and Ankle Society (AOFAS) midfoot scale, complications, and all-cause re-operation rates were secondary outcome measures. Univariate and multivariate analyses were used to identify risk factors associated with poorer outcomes. Results. Mean follow-up 40.8 months (24–72). Mean MOXFQ-Index 27.0 (SD 7.1). Mean AOFAS score 72.6 (SD 11.6). 48/85 patients had injury patterns that included an intra-articular fracture and this was associated with poorer outcomes, with worse MOXFQ and AOFAS scores (both p < 0.001). 18 patients (21%) required the removal of metalwork for either prominence or stiffness. Female patients were more likely to require metalwork removal (OR 3.89, 95% CI 1.27 to 12.0, p = 0.02). Eight patients (9%) required secondary arthrodesis. Conclusions. This is the largest series of Lisfranc injuries treated with dorsal bridge plate fixation reported to date and the only to routinely retain metalwork. The technique is safe and effective. The presence of an intraarticular fracture is a poor prognostic indicator. Metalwork removal is more likely to be needed in female patients but routine removal may not be essential

Background. Lisfranc fracture dislocations are uncommon injuries, which frequently require surgical intervention. Currently, there is varying evidence on the diagnostic utility of plain radiographs (XR) and CT in identifying Lisfranc injuries and concomitant fractures. Our aim was to identify the utility of XR as compared to CT, with the nul hypothesis that there was no difference in fracture identification. Methods. A retrospective assessment of patients who had sustained a Lisfranc injury between 2013 and 2022 across two trauma centres within the United Kingdom who underwent surgery. Pre-operative XR and CT images were reviewed independently by 2 reviewers to identify the presence of associated fractures. Results. A total of 175 patients were included. Our assessment identified that XR images significantly under-diagnosed all metatarsal and midfoot fractures. The largest discrepancies between XR and CT in their rates of detection were in fractures of the cuboid (5.7% vs 28%, p<0.001), medial cuneiform (20% vs 51%, p=0.008), lateral cuneiform (4% vs 36%, p=0.113), second metatarsal (57% vs 82%, p<0.001), third metatarsal (37% vs 61%, p<0.001) and fourth metatarsal (26% vs 43%, p<0.001). As compared to CT, the sensitivity of XR was low. The lowest sensitivity for identification however was lateral foot injuries, specifically fractures of the lateral cuneiform (sensitivity 7.94%, specificity 97.3%), cuboid (sensitivity 18.37%, specificity 99.21%), fourth (sensitivity 46.7%, specificity 89.80%) and fifth metatarsal (sensitivity 45.00%, specificity 96.10%). Conclusion. From our analysis, we can determine that XR significantly under-diagnoses associated injuries in patient sustaining an unstable Lisfranc injury, with lateral foot injuries being the worst identified. We advised the use of CT imaging in all cases for appropriate surgical planning

Lisfranc injuries are not the common injuries of foot and ankle but there has been an increase in the incidence of these injuries due to road traffic accidents and fall from heights. We wish to present our retrospective case series of the operative management of the Lisfranc injuries by our senior author. We retrospectively reviewed 68 patients with Lisfranc injuries who were managed operatively by the senior author over the last six years. The case note and the radiographs including the CT scans were reviewed. All of them were treated with open reduction and internal fixation within three weeks of injury. The male: female ratio was 43:25. 37 right: 31 left sided injuries. The average age was 40.6 years (range 16 – 81 years). The most common mechanism of injury was fall from steps at home followed by motor bike accident. They average follow-up was 19.5 months and they were assessed both clinically and radiographically at each follow-up. The k wires were removed at an average of six weeks. 96% were pain free and fully weight bearing after six months. Two patients had lateral scar tenderness. Majority of them returned to normal activities at an average of 12 months. Two patients had initial wound complications which were treated successfully with oral antibiotics. None of them had degenerative changes. Our results of early open reduction and internal fixation were comparable to the published literature

The anatomy of the mortise of the Lisfranc joint between the medial and lateral cuneiforms was studied in detail, with particular reference to features which may predispose to injury. In 33 consecutive patients with Lisfranc injuries we measured, from conventional radiographs, the medial depth of the mortise (A), the lateral depth (B) and the length of the second metatarsal (C). MRI was used to confirm the diagnosis. We calculated the mean depth of the mortise (A+B)/2, and the variables of the lever arm as follows: C/A, C/B and C/mean depth. The data were compared with those obtained in 84 cadaver feet with no previous injury of the Lisfranc joint complex. Statistical analysis used Student’s two-sample t-test at the 5% error level and forward stepwise logistic regression. The mean medial depth of the mortise was found to be significantly less in patients with Lisfranc injuries than in the control group. Stepwise logistic regression identified only this depth as a significant risk factor for Lisfranc injuries. The odds of being in the injury group is 0.52 (approximately half) that of being a control if the medial depth of the mortise is increased by 1 mm, after adjusting for the other variables in the model. Our findings show that the mortise in patients with injuries to the Lisfranc joint is shallower than in the control group and the shallower it is the greater is the risk of injury

Aim. Anatomical reduction and Stable fixation of Lisfranc injuries is considered the gold standard. There is controversy about how it is best achieved. Some surgeons would advocate routine open anatomical reduction, which as a concept was popular in 1980s but the same anatomical reduction and fixation can be achieved percutaneously. We describe our method of close reduction and percutaneous fixation and present our results. Materials and methods. 22 patients with a minimum follow up of 12 months were included. We achieved satisfactory anatomical reduction percutaneously in all patients and internal fixation was performed using cannulated screws for medial and middle columns. Functional outcome was evaluated using Foot and Ankle Disability Index (FADI) and components of this score were analysed individually to assess which domain was most affected. Vertical ground reaction forces were measured using a force plate in a walking platform. Results. The average age at operation was 48 years (17–67). Mean follow up was 20 months (13–60). The average Foot & Ankle Disability Index at final follow up was 79 (66–94). No loss of reduction or metal breakage was noted. Walking on uneven surface, going down stairs, heavy work and pain first thing in the morning were the domains of functional Index that showed poor recovery. None of the patients had pain at rest. Only three patients found it extremely hard to return to recreational activities. None of the patients had problems related to wound. Gait analysis showed a prolonged push-off (p=0.22) and significantly prolonged pre-swing phase (p=0.015) of the affected limb. Conclusions. Percutaneous reduction and fixation technique for Lisfranc injuries provides predicatable good functional outcome and gait pattern similar to open tecchinques with a potentially decreased risk of wound problems

The diagnosis of Lisfranc ligament disruption is notoriously difficult. Radiographs and MRI scans are often ambiguous therefore a stress-test examination under anaesthesia is commonly required. Two midfoot stress-tests are in current practice, namely the varus first ray stress-test and the pronation abduction test. The optimal type of stress-test is not however evaluated in the literature. We hypothesised that after the loss of the main plantar stabiliser (the Lisfranc ligament) the patient would demonstrate dorsal instability, not the classic 1. st. /2. nd. metatarsal diastasis commonly described. We therefore devised a push-up test (placement of a force under the 2. nd. metatarsal in an attempt to elevate the base away from the middle cuneiform on the lateral radiograph). We aimed to initially test our hypothesis on a cadaveric model. Twelve fresh frozen cadaveric specimens without previous foot injury were used. The 2. nd. tarsometatarsal joint was exposed and the Lisfranc ligament and dorsal capsule were incised. An image intensifier was positioned and standard anteroposterior (AP) and lateral views were obtained. Two previously reported AP stress-tests (varus first ray stress test, pronation abduction test) and the novel test under investigation (‘Lisfranc Push-Up’ test) were duly performed. Images were obtained once the investigator felt the appropriate views were achieved. All twelve of the Lisfranc Push-Up tests showed dorsal subluxation of the 2. nd. metatarsal on the middle cuneiform of greater than 2mm on the lateral radiograph. No diastasis of the 1. st. /2. nd. metatarsals was seen in any of the specimens on the AP radiograph for either of the other two stress-tests. The authors have described a novel way of demonstrating the dorsal instability associated with the ligamentous Lisfranc injury. Our results support the Lisfranc Push-Up test as a reproducible and sensitive method for assessing ligamentous Lisfranc injuries. In our cadaveric model the previously described stress-tests do not work

Introduction. We describe a novel single incision approach and its safety in the largest reported series of Lisfranc injuries to date. Via separate subcutaneous windows it is possible to access the medial three rays of the foot for bridge plating, without the concern of narrow skin bridges between multiple incisions. Methods. A retrospective review identified all 150 patients who underwent a Lisfranc ORIF via the modified dorsal approach at the Royal Melbourne Hospital between January 2011 and June 2016. All patients were operated by a single surgeon. Removal of metalwork (ROM) was routinely undertaken at six months post-operatively via the same incision. Medical recored were reviewed to record patient demographics, mechanism of injury and surgical details. Outpatient notes were reviewed to identify wound-related complications including; delayed wound healing, superficial infection, wound dehiscence, deep infection, complex regional pain syndrome (CRPS), neuroma and impaired sensation. Median follow-up was 1012 days (range 188–2141). Results. Median age was 37 years (19–78). 110 (73%) patients were male. Mechanism of injury was: motor vehicle accident (37%), motor bike accident (19%) and fall (18%). 24 (16%) injuries were open, 5 of which required soft tissue reconstruction at the primary surgery. A total of 34 wound related complications occurred (22%); superficial infection (14), delayed wound healing (7), wound dehiscence (5), CRPS (4), impaired sensation (3), neuroma (1). Re-operation was necessary in the 5 patients who experienced wound dehiscence; 4 requiring split skin grafts and 1 requiring a free flap. Crush injuries were 10 times more likely to have wound complications than those sustained in motor vehicle accidents. Patients undergoing ROM were more likely to have wound complications than those who did not. Conclusion. The modified dorsal approach using subcutaneous windows to access the midfoot joints offers a viable alternative to existing approaches

Aims

The aim of this retrospective study was to compare the functional and radiological outcomes of bridge plating, screw fixation, and a combination of both methods for the treatment of Lisfranc fracture dislocations.

Background. Lisfranc/midfoot injuries are complex injuries with a reported incidence of 1 in 55000 in literature and frequently overlooked. But, recently they are becoming more commonly diagnosed with advent of CT scan and examination under anaesthesias (EUA) for suspicion fractures. Here we present a case series results of a single surgeons experience over the last 6 years. Methods. Retrospective review of 68 patients treated by a single surgeon over the last 6 years. Injuries were diagnosed on plain Xrays, clinic examination. Any suspicious injury were further assessed by a CT scan, all injuries were confirmed by EUA and treated with open reduction and internal fixation within 4 weeks of injury. Post-operative immobilisation in full cast for 6 weeks then a removal boot with non-weight bearing for a total of 3months. They were followed up regularly initially at 3, 6 and 12months. At final review the following data was collected: clinical examination, plain x-ray looking for: late deformity, signs of OA in Lisfranc joint, Auto fusion rate, rate of metal work failure. The x-rays findings were correlated with: (1) type of fixation. (2) The following scores: FAOS, AOFAS-M, specially designed new foot and ankle score. Results. 43 males: 25 females. 37 right: 31 left sided injuries. 90% were fully weight bearing with minimal discomfort after 6months. In 12 months all of them returned to their normal daily life activities. Wound complications: 2 of them had initial wound complications which were treated successfully with 2 weeks of oral antibiotics, 2 had lateral scar tenderness. One had loosened metal work, revised to fusion. Conclusion. Early operative intervention with good anatomical reduction can minimise the potential chronic disability associated with these injuries. This is a largest series of Lis-franc injuries of a single surgeon with good clinical outcome following surgical fixation

Aims

The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee.

Aims

Fractures of the navicular can occur in isolation but, owing to the intimate anatomical and biomechanical relationships, are often associated with other injuries to the neighbouring bones and joints in the foot. As a result, they can lead to long-term morbidity and poor function. Our aim in this study was to identify patterns of injury in a new classification system of traumatic fractures of the navicular, with consideration being given to the commonly associated injuries to the midfoot.

We present a review of litigation claims relating to foot and ankle surgery in the NHS in England during the 17-year period between 1995 and 2012.

A freedom of information request was made to obtain data from the NHS litigation authority (NHSLA) relating to orthopaedic claims, and the foot and ankle claims were reviewed.

During this period of time, a total of 10 273 orthopaedic claims were made, of which 1294 (12.6%) were related to the foot and ankle. 1036 were closed, which comprised of 1104 specific complaints. Analysis was performed using the complaints as the denominator. The cost of settling these claims was more than £36 million.

There were 372 complaints (33.7%) involving the ankle, of which 273 (73.4%) were related to trauma. Conditions affecting the first ray accounted for 236 (21.4%), of which 232 (98.3%) concerned elective practice. Overall, claims due to diagnostic errors accounted for 210 (19.0%) complaints, 208 (18.8%) from alleged incompetent surgery and 149 (13.5%) from alleged mismanagement.

Our findings show that the incorrect, delayed or missed diagnosis of conditions affecting the foot and ankle is a key area for improvement, especially in trauma practice.

Cite this article: Bone Joint J 2014;96-B:1510–14.