Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings.

BACKGROUND The objective of the present study was to assess the utility of magnetic resonance imaging for the diagnosis of an injury to the Lisfranc and adjacent ligaments and to determine whether conventional magnetic resonance imaging is a reliable diagnostic tool, with manual stress radiographic evaluation with the patient under anesthesia and surgical findings being used as a reference standard. METHODS Magnetic resonance images of twenty-one feet in twenty patients (ten women and ten men with a mean age of 33.6 years [range, twenty to fifty-six years]) were evaluated with regard to the integrity of the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal-metatarsal ligaments, and the medial-middle cuneiform ligament. Furthermore, the presence of fluid along the first metatarsal base and the presence of fractures also were evaluated. Radiographic observations were compared with intraoperative findings with respect to the stability of the Lisfranc joint, and logistic regression was used to find the best predictors of Lisfranc joint instability. RESULTS Intraoperatively, seventeen unstable and four stable Lisfranc joints were identified. The strongest predictor of instability was disruption of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals (the pC1-M2M3 ligament), with a sensitivity, specificity, and positive predictive value of 94%, 75%, and 94%, respectively. Nineteen (90%) of the twenty-one Lisfranc joint complexes were correctly classified on magnetic resonance imaging; in one case an intraoperatively stable Lisfranc joint complex was interpreted as unstable on magnetic resonance imaging, and in another case an intraoperatively unstable Lisfranc joint complex was interpreted as stable on magnetic resonance imaging. The majority (eighteen) of the twenty-one feet demonstrated disruption of the second plantar tarsal-metatarsal ligament, which had little clinical correlation with instability. CONCLUSIONS Magnetic resonance imaging is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. Rupture or grade-2 sprain of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals is highly suggestive of an unstable midfoot, for which surgical stabilization has been recommended. The appearance of a normal ligament is suggestive of a stable midfoot, and documentation of its integrity may obviate the need for a manual stress radiographic evaluation under anesthesia for a patient with equivocal clinical and radiographic examinations.

[1]  J. Ward,et al.  Anatomy of the Lisfranc Ligament , 2008, Foot & ankle specialist.

[2]  S. Kaar,et al.  Lisfranc joint displacement following sequential ligament sectioning. , 2007, The Journal of bone and joint surgery. American volume.

[3]  B. Mucci,et al.  Lisfranc injury: how frequently does it get missed? And how can we improve? , 2007, Injury.

[4]  A. Zoga,et al.  MRI of trauma to the foot and ankle. , 2006, Seminars in musculoskeletal radiology.

[5]  Thuan V Ly,et al.  Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. , 2006, The Journal of bone and joint surgery. American volume.

[6]  S. Koskinen,et al.  Lisfranc Fracture-dislocation in Patients with Multiple Trauma: Diagnosis with Multidetector Computed Tomography , 2004, Foot & ankle international.

[7]  W Grechenig,et al.  The anatomy of the joint as a risk factor for Lisfranc dislocation and fracture-dislocation. An anatomical and radiological case control study. , 2002, The Journal of bone and joint surgery. British volume.

[8]  M. Patterson Lisfranc's or tarsometatarsal fracture-dislocation. , 2000, International journal of trauma nursing.

[9]  M. Usnr,et al.  Abduction Stress and AP Weightbearing Radiography of Purely Ligamentous Injury in the Tarsometatarsal Joint , 1998, Foot & ankle international.

[10]  H. Potter,et al.  Magnetic Resonance Imaging of the Lisfranc Ligament of the Foot , 1998, Foot & ankle international.

[11]  Attilio Santucci,et al.  Anatomy of the Lisfranc Joint Complex , 1997, Foot & ankle international.

[12]  D. Resnick,et al.  MR imaging of the tarsometatarsal joint: analysis of injuries in 11 patients. , 1996, AJR. American journal of roentgenology.

[13]  D. Resnick,et al.  Tarsometatarsal joint: anatomic details on MR images. , 1996, Radiology.

[14]  M. Myerson,et al.  Tarsometatarsal joint injuries in the athlete , 1993, The American journal of sports medicine.

[15]  Robert T. Burks,et al.  Subtle injuries of the Lisfranc joint. , 1990, The Journal of bone and joint surgery. American volume.

[16]  M. Myerson The diagnosis and treatment of injuries to the Lisfranc joint complex. , 1989, The Orthopedic clinics of North America.

[17]  J. Kenzora,et al.  Fracture Dislocations of the Tarsometatarsal Joints: End Results Correlated with Pathology and Treatment , 1986, Foot & ankle.

[18]  L. Gilula,et al.  Subtleties of Lisfranc fracture-dislocations. , 1981, AJR. American journal of roentgenology.

[19]  S. Raikin,et al.  A Lisfranc fracture-dislocation in a football player. , 2003, The Journal of the American Board of Family Practice.