Extract
The Chopart joint, also known as the midtarsal or transverse tarsal joint, consists of the calcaneocuboid and talonavicular joints. These two joints lie in a plane perpendicular to the longitudinal arch of the foot, and act as a single unit with respect to the hindfoot. The Lisfranc joint consists of the tarsometatarsal joint complex, which includes the medial, middle, and lateral cuneiforms; the cuboid; and the articulations with the five metatarsal bases. The navicular cuneiform articulations, and the articulation between the navicular and cuboid bones, do not specifically have their own eponym. The Lisfranc joint forms the osseous and ligamentous foundation of the longitudinal and transverse arches (Fig. 1).
The Chopart joint, also known as the midtarsal or transverse tarsal joint, consists of the calcaneocuboid and talonavicular joints. These two joints lie in a plane perpendicular to the longitudinal arch of the foot, and act as a single unit with respect to the hindfoot. The Lisfranc joint consists of the tarsometatarsal joint complex, which includes the medial, middle, and lateral cuneiforms; the cuboid; and the articulations with the five metatarsal bases. The navicular cuneiform articulations, and the articulation between the navicular and cuboid bones, do not specifically have their own eponym. The Lisfranc joint forms the osseous and ligamentous foundation of the longitudinal and transverse arches (Fig. 1).
Midfoot fractures, including those involving the Chopart and Lisfranc joints, can be very easy to miss because of their rarity, the lack of obvious radiographic findings in up to 33% of such injuries, and the lack of familiarity with such fractures by many treating physicians1. Chopart joint injuries are extremely rare2. Injuries to the Lisfranc joint complex are uncommon, accounting for only 0.2% of fractures, or one in 55,000 people each year3. Approximately one-third are due to low-energy trauma such as sports injuries4,5. To make matters more confusing, injuries to the Lisfranc or Chopart joint are frequently combined with other midfoot injuries.
The Chopart joint is composed of the condyloid talonavicular joint and the saddle-shaped calcaneocuboid joint. These two joints invert and evert with the subtalar joint. The talonavicular joint is stabilized in part by the acetabulum pedis, a deep socket that contains the head of the talus. It is composed of the concave proximal surface of the navicular, the anterior and middle facets of the calcaneus, the spring ligament, and the bifurcate Y-shaped ligament (Fig. 2). The calcaneocuboid joint is concave vertically and convex transversely, forming the articulation between the anterior process of the calcaneus and the cuboid. This highly congruent joint “locks in” during step-off.
The Lisfranc joint is a combination of the tarsometatarsal, anterior intertarsal, and proximal intermetatarsal joints and is critical to the longitudinal and transverse arches of the foot. Transverse stability is provided by the trapezoidal “Roman arch” architecture of the complex. Longitudinal stability is provided primarily by the second metatarsal base, which acts as a keystone to the joint complex. The first three metatarsals each articulate with a cuneiform, while the fourth and fifth metatarsals each articulate with a separate facet of the cuboid (Fig. 1). The stability of these joints is dependent on ligamentous support.
The joint capsules of the Lisfranc complex are divided into three compartments: the medial (first tarsometatarsal joint), central (second and third tarsometatarsal joints), and lateral (fourth and fifth tarsometatarsal joints). Ligaments are best grouped as dorsal, interosseous, and plantar. Dorsal ligaments follow a transverse, oblique, and longitudinal orientation. The interosseous ligaments are the strongest of the Lisfranc complex and are important in the stability of the joint. Interosseous ligaments join the second through fifth metatarsals together, but there are none between the first and second metatarsal. Rather, the Lisfranc ligament joins the second metatarsal to the medial cuneiform, securing the medial column to the intermediate and lateral columns. The Lisfranc ligament is the largest and strongest interosseous ligament, and is responsible for the avulsion fragment off the plantar second metatarsal base commonly seen in fracture-dislocations (Fig. 3). Plantar ligaments are substantially stronger than their corresponding dorsal counterparts, helping to maintain the “Roman arch” architecture of the midfoot.
The dorsalis pedis artery crosses the Lisfranc joint and courses between the first and second metatarsal bases to the plantar surface to form the plantar arch. It may be avulsed or thrombosed in a fracture-dislocation, resulting in hematoma or compartment syndrome. The deep peroneal nerve follows the dorsalis pedis artery and provides innervation to the first dorsal web space.
While many tendons cross the Chopart and Lisfranc joints, the tibialis anterior and peroneus longus are the most important. The tibialis anterior inserts onto the dorsum of the first metatarsal base and medial cuneiform, providing dynamic stability to the first tarsometatarsal joint. In ipsilateral dislocations, the tibialis anterior tendon may become entrapped between the middle and medial cuneiforms, blocking reduction. The peroneus longus inserts onto the plantar-lateral surface of the first metatarsal, dynamically supporting the transverse and longitudinal arches of the foot.
Normal anatomy and biomechanics of the midfoot are best understood with use of the column theories. The Chopart joint is the flexible medial column, involving the talus and navicular and the lateral column, which includes the calcaneus and cuboid. The rest of the medial column is rigid and made up of the cuneiforms and the first, second, and third metatarsals, while the rest of the lateral column is flexible and is made up of the fourth and fifth metatarsals. In the midfoot, the middle and medial cuneiform, second and third metatarsals, and their associated rays are the intermediate or the middle column. Approximately 3.5 mm of dorsal-plantar motion occurs in the medial column. Rigidity is provided by the intermediate column, while the mobile lateral column provides shock absorption.
The Chopart joint allows the hindfoot to pivot, while the forefoot remains stationary. This joint complex, together with the subtalar joint, functions as a unit to invert and evert the foot6. When the heel is everted, the calcaneocuboid and talonavicular joints are parallel, allowing for motion across the Chopart joint. When the heel is inverted, the two joints are not parallel and “lock,” becoming immobile to stabilize the midfoot during the push off phase of gait (Fig. 4). Furthermore, a windlass mechanism is provided by the plantar aponeurosis, which locks the midfoot and stiffens the longitudinal arch. During push off, dorsiflexion of the first metatarsophalangeal joint tightens the aponeurosis and plantar fascia, elevating the arch and inverting the calcaneus.
Most midtarsal joint and tarsometatarsal joint injuries occur through an axial load or twisting force applied to the plantar flexed foot7,8. Fracture dislocations most frequently occur at the first and second metatarsal bases with secondary medial or lateral dislocation depending on direction of force. Forceful abduction often leads to fracture-dislocation of the second metatarsal base with an associated cuboid crush fracture referred to as a “nutcracker” injury.
Although less common, a crush injury or direct blow from a falling object onto the dorsum of the midfoot may lead to injury7-9. These injuries can be devastating with associated severe soft-tissue injury, neurovascular injury and/or compromise, and the potential development of foot compartment syndrome10.
If the tarsometatarsal joint is disrupted on the radiograph, but the clinical history is unremarkable, the clinician must consider Charcot neuroarthropathy. While Charcot neuroarthropathy affects a small percentage of diabetic neuropathic patients11,12, the midfoot is the most common location. It can be the presenting finding of diabetes in some patients. In this setting, appropriate diagnosis and treatment can be limb and life-saving.
Main and Jowett, in 1975, suggested a classification system based on the mechanism of midfoot injury2; however, the classification system described by Quénu and Küss in 190913, which was later modified in 1982 by Hardcastle et al.9, noting three primary patterns of injury—divergent, isolated, and homolateral—has maintained greater acceptance. This classification system provides a helpful framework because it implies that energy enters and exits the midfoot at different locations, a principle that is fundamental to diagnostic and treatment options. Those authors divided the injuries into three patterns: Type A, indicating total incongruity; Type B, partial incongruity; and Type C, divergent. Myerson et al.7, in 1986, further divided Types B and C, with Type B1 indicating partial incongruity with medial displacement; Type B2, partial incongruity with lateral displacement; Type C1, a divergent pattern with partial displacement; and Type C2, total displacement. They described these injuries as involving not only the tarsometatarsal joints but also the intercuneiform and naviculocuneiform joints (Fig. 5).
A high clinical suspicion for midfoot injury is indicated when a patient has pain and swelling of the foot with plantar ecchymosis on presentation14. Up to 20% of injuries are initially missed15. Standard imaging includes anteroposterior, lateral, and oblique radiographs of the foot, made parallel to the tarsometatarsal joints. Displacement of >2 mm between the medial cuneiform and second metatarsal base indicates instability (Fig. 3). The pathognomic finding of tarsometatarsal injury, the “fleck sign,” may also be seen on radiographs. This is a fleck of bone between the first and second metatarsal bases and represents an avulsion fracture of the Lisfranc ligament7. A computed tomography (CT) scan may be used to better visualize fracture patterns, but as CT scans are static and made without weight-bearing, they are not generally helpful in determining stability. Fleck signs or avulsion fractures can be subtle yet represent instability.
If non-weight-bearing radiographs have normal findings, then weight-bearing radiographs should be made. Standing anteroposterior radiographs of both feet on one cassette are particularly helpful to look for subtle side-to-side differences. In addition to looking for subluxation of joints and fractures, one must assess alignment of the foot radiographically, as the talus-navicular-medial cuneiform-first metatarsal should be lined up on both a lateral and anteroposterior radiograph of the foot as shown by the red lines in Figures 1-A and 1-C. Patients may be unable to fully bear weight, leading to an inconclusive study. In this situation, a manual stress examination with the patient under anesthesia is recommended to rule out instability4,16,17. While the patient is under anesthesia, two stresses are applied. First, the foot is abducted and pronated. Second, the medial and middle columns are compressed together. Either of these provocative maneuvers may create displacement through the tarsometatarsal joints. It is also helpful to attempt to flex the midfoot through the Lisfranc joint on a lateral dynamic image to assess for subluxation or gapping of the dorsal joints.
If the diagnosis is still unclear, a magnetic resonance imaging (MRI) scan can evaluate the midfoot soft tissues (Fig. 6). Recently, Raikin et al. correlated MRI findings with stress examinations18. They showed a high correlation between rupture of the plantar Lisfranc ligament and instability. They also described a clinical algorithm to help to determine which patients need to undergo stress examinations, which are generally reserved for patients with intact plantar Lisfranc ligament but a positive fleck sign. An MRI is a static image that cannot detect instability.
Nonoperative treatment is reserved for nondisplaced and stable injuries only. A short leg cast is applied, and no weight-bearing is allowed for four to six weeks. As symptoms resolve, the patient can begin weight-bearing in a boot or custom-molded orthosis19,20. Joint displacement through the tarsometatarsal joint complex with or without a stress examination is an indication for operative intervention.
Initially, the acute Lisfranc and Chopart injury is reduced to relieve pressure on the surrounding soft tissues to ensure skin viability. When the reduction is stable, the patient can be managed with a splint until definitive treatment is done, usually within two weeks. Unfortunately, most high-energy Lisfranc injury reductions are not stable. In these cases, the reduction is stabilized by placing an external fixator and, if necessary, one or two Kirschner wires are added. Unstable interim reductions may lead to soft-tissue damage, which can compromise foot viability, sometimes with full-thickness skin necrosis. Malaligned midfoot fractures are difficult or impossible to reduce anatomically after soft-tissue swelling has resolved and too much time has been allowed to elapse. Satisfactory interim provisional reduction promotes resolution of swelling more quickly.
Unicolumnar frames stabilize a shortened lateral column, which is due to displacement of the fourth and fifth metatarsal-cuboid complex or to a crushed cuboid. Bicolumnar frames are used when both the lateral and medial columns are injured or shortened, such as in injuries caused by an axial load through the midfoot, where the cuboid, navicular, and/or cuneiforms are crushed (Fig. 7). Details of the techniques used to place external fixators and the care required before definitive treatment have been previously described21. Patients with Lisfranc injuries should be assessed for gastrocnemius tightness, which is associated with a relative equinus condition at the ankle22. If they have gastrocnemius tightness21, a gastrocnemius recession should be performed in the same surgical setting in advance of the definitive treatment of the Lisfranc injury itself. Definitive open reduction and internal fixation is done when soft-tissue swelling is sufficiently decreased.
There are essential and nonessential joints of the midfoot. Essential joints are those essential to midfoot function because of the motion required at those joints. Nonessential joints have minimal to no motion. Every attempt must be made to reconstruct and preserve essential joints. Nonessential joints may be fused, and permanent implants may be placed across these joints. The essential joints of the midfoot include the talonavicular and the calcaneocuboid, as well as the articulations between the cuboid and the fourth and fifth metatarsals. The nonessential joints include all of the rest: the first, second, and third metatarsocuneiform joints; the intercuneiform joints; and the naviculocuneiform joint.
Internal fixation is guided by two basic strategies. First, stability of the medial column must be obtained even at the cost of restriction of tarsometatarsal motion by fixing the first, second, and third metatarsals to the adjacent cuneiforms. Second, motion of the lateral column (between the fourth and fifth metatarsal and the cuboid) and of the talonavicular joint must be maintained.
In general, reduction of the Lisfranc injury follows a pattern of proximal to distal and of medial to lateral. Reductions are performed and maintained with provisional fixation with Kirschner wire, if needed. The medial frame is removed before the medial column is reduced, and if maintenance of length is a problem, then provisional Kirschner wires can be placed before the external fixator is removed.
Navicular fractures are reduced first, followed by the cuneiform fractures. Cuboid fractures are reduced after definitive fixation of the medial column tarsometatarsal disruptions. The tarsometatarsal disruptions are reduced as needed through skin incisions and muscle dissections detailed in Table I21. It is important to be familiar with these common intervals, but often variations are necessary to incorporate fracture combinations or lacerations in the foot. The foot may be accessed from medial, lateral, and dorsal, but it is never approached via the plantar surface despite the plantar comminution often seen in CT scans at the bases of the metatarsal cuneiform joints. The lateral frame may be left in place as long as eight weeks after definitive fixation if the fixation of the cuboid or calcaneal anterior process is complex, in order to protect the fixation of a comminuted lateral column during the phase of earlier mobilization, stretching, and massage.
Step 1: Provisional Fixation of the Medial Column
The first metatarsal is manipulated to reduce its proximal joint surface onto the articulation of the medial cuneiform. The soft tissues are retracted medially to allow visualization and assessment of the reduction of the medial border of the medial cuneiform to the first metatarsal. Any gap or translational displacement must be eliminated for a perfect reduction. Provisional fixation is done with Kirschner wires until definitive fixation is complete. At the first, second, and third tarsometatarsal reductions, one Kirschner wire provides stability and the second wire is a guide for the definitive fixation (Figs. 8-A, 8-B, and 8-C).
Through incision A, the second metatarsal base is keyed into its position as the keystone of the arch (Table I). The lateral side is viewed via a capsulotomy of the second metatarsal-intermediate cuneiform joint. It is important to ensure that both medial and lateral sides are reduced. Provisional fixation is done with a Kirschner wire placed just lateral to the medial edge and central to the second metatarsal. Incision B is used to access the base of the third metatarsal and lateral cuneiform (Table I).
Step 2: Definitive Fixation of the Lateral Column
The lateral column is managed after the medial column has been temporarily fixed. The bases of the fourth and fifth metatarsals are often dorsally displaced, which is seen radiographically as a diffuse separation rather than a crisp joint surface. Reduction by manipulation is recognized when there is a congruent joint line on the oblique radiograph at the medial edge of the cuboid. Direct visualization of the lateral reduction is possible through incision C (Table I). A Kirschner wire is placed from the fourth metatarsal base through the joint surfaces to the medial corner of cuboid. From the lateral surface of the fifth metatarsal, another wire is placed in the fifth metatarsal through the center of the joint to the medial corner of the cuboid.
It is our preference to clip all wires under the skin to mitigate skin problems, which are common because of swelling.
Step 3: Definitive Fixation of Medial Column
Definitive fixation of the navicular and cuneiforms can be done with joint-spanning implants, which provide maximal stability. The first tarsometatarsal joint is definitively fixed with two screws (Figs. 8-D, 8-E, and 8-F). A screw is inserted from the lateral side of the first metatarsal, in a proximal and plantar direction, into the medial cuneiform. This screw placement creates no prominence of the screw head, which, if placed dorsally, can irritate the extensor hallucis longus. Another screw is placed from the medial cuneiform to the plantar prominence of the first metatarsal base. The central Kirschner wire is replaced with a 3.5-mm screw or “Lisfranc” 4.0-mm screw to definitively fix the second and third metatarsals. The 3.5-mm and 4.0-mm screws with 2.7-mm heads are less irritating to the extensor tendons. Donati-Allgöwer sutures are used to close the skin incision as this technique has been shown to preserve blood supply to the skin edges23.
The foot is placed in a well-padded dressing and is maintained in a plantigrade position and splinted with well-molded plaster held on with an Ace bandage. The elastic bandage allows for volumetric changes of the ankle due to swelling. If a lateral column frame was used, we continue to manage the patient with antibiotics (Bactrim [trimethoprim and sulfamethoxazole] or ciprofloxacin) for six to eight weeks, until the frame is removed. Quadriceps-locking exercises, designed to straighten the knee to stretch the gastrocnemius, are begun immediately. Care is taken to prevent an ankle equinus contracture.
Sutures are removed two weeks after surgery. If a gastrocnemius recession was performed, the foot is placed in a short-leg fiberglass cast with the ankle in neutral position unless there is an external fixator frame on the foot, in which case it is splinted. Passive range of motion of the metatarsophalangeal joints and active range of motion of the hip and knee are started. Six weeks postoperatively, the cast is removed and the patient wears a boot. Between six and ten weeks after surgery, patients with lateral frames have the frames removed as well as the pins that were placed across the fourth and fifth metatarsal-cuboid joint. Active ankle and subtalar joint motion is begun, and weight-bearing on the heel with the boot on is allowed as tolerated.
The patient walks with a flatfoot gait in a boot with compressive stockings. Orthotics can be used at this juncture. Three months postoperatively, the patient begins to roll over the forefoot with the boot on (Figs. 8-G, 8-H, and 8-I), and at this time normal shoe wear is initiated. At six to nine months, a fitted semicustom insert is made for shoe use if the patient is symptomatic or if needed because of the severity of the initial injury. Exercises that strengthen and stretch the gastrocnemius to keep the motion provided by the gastrocnemius recession should be emphasized to the patient. Advanced balance and proprioceptive training for lower-extremity function is begun at this time. At one year postoperatively, the patient returns for a final follow-up evaluation.
Complications related to midfoot injuries are common. The complications can be grouped into nonoperative and operative categories. The nonoperative complications are a missed injury or deformity, such as planovalgus24, and posttraumatic arthritis. Skin or wound-healing problems are related to operative timing (too early), operative technique (undermining wound edges or creating flaps), and wound spacing between intervals. Dorsal neural structures such as the deep peroneal (first web space), superficial peroneal, and sural nerves may be injured with the surgical approach or with aggressive retraction. Attention to detail and knowledge of the neighboring anatomy are paramount. Allowing unstable injuries to shorten without maintenance of length, followed by operative lengthening and stabilization, or missed compartmental syndrome25 may create a regional pain syndrome and can be avoided with temporary external fixation. Injury to the anterior tibialis artery is the most common vascular injury. Because of the subcutaneous position of the implants, prominent screw heads or plates can be extremely bothersome to surrounding neural structures or with shoe wear. Failed fixation from inadequate stability or fixation can result in loss of fixation, broken implants, and midfoot collapse26. In addition, continued foot pain, whether or not it is treated with surgical intervention, can be associated with posttraumatic contracture of the heel cord27-29.
In a retrospective evaluation of forty-eight tarsometatarsal injuries at an average follow-up of 4.5 years, the average functional outcome scores were 77 points on the American Orthopaedic Foot & Ankle Society (AOFAS) scoring system and 19 points on the Musculoskeletal Function Assessment (MFA) scoring system30. One-quarter of the patients had posttraumatic arthritis, and 12.5% of the patients required revision salvage arthrodesis. Rigid anatomic fixation produced the best results. The purely ligamentous injuries performed the worst, with 40% having symptomatic posttraumatic arthritis compared with only 18% of the combined ligamentous and osseous injuries. In an analysis of twenty-five patients who had midfoot injuries treated with open reduction and internal fixation (ORIF), injuries to one column of the foot resulted in patients preferentially bearing weight on the noninjured column or loading the longer column31. The amount and severity of arthritis did not influence the gait. Comminution with loss of column length shifted the foot axis in the sagittal or coronal plane, affecting the gait pattern and subsequent symptoms. Bicolumnar injuries have worse clinical and functional outcomes compared with medial or lateral column injuries. Obesity was also a predictor of inferior results32.
The Debate of Fusion Versus Open Reduction and Internal Fixation
The foot has functional columns and joints22. The medial column, where the navicular is the keystone, requires rigidity for stability, while the lateral column, where the cuboid is the keystone, requires flexibility for mobility. This principle was discussed earlier with use of the terms “essential” joints (those that require motion) and “nonessential” joints (those that have minimal motion to begin with). Therefore, the role of the columns and joints are important to potential treatment options such as temporary Kirschner-wire fixation, ORIF, or arthrodesis.
In a prospective randomized trial of primary arthrodesis compared with ORIF of the medial three rays (first, second, and third tarsometatarsals), twenty patients underwent ORIF and twenty-one had a primary arthrodesis33. Anatomic reductions were performed in eighteen of twenty patients who had ORIF and in twenty of twenty-one patients who had primary arthrodesis. After a mean 4.5-year follow-up period, reoperations were done in five of twenty patients who had ORIF secondary to posttraumatic arthritis, whereas none of the patients who had primary arthrodesis required secondary surgery. The average AOFAS score was 68.6 points for the ORIF group and 88 points for the group that had primary arthrodesis. The average postoperative activity level was 65% of the preinjury level for the ORIF group and 92% for the primary arthrodesis group. Better short and medium-term function was noted with primary arthrodesis compared with ORIF.
In another analysis of ORIF compared with primary arthrodesis, twenty-two patients were randomized to ORIF and seventeen to primary arthrodesis34. Patients were followed for a minimum of two years. Anatomic reductions were performed in twenty-one of twenty-two patients who had ORIF and in sixteen of seventeen who had primary arthrodesis. The reoperation rate was 78.6% after ORIF, because of posttraumatic arthritis and implant removal, compared with a rate of 16.7% after primary arthrodesis, because of prominent bothersome implants. The Short Form-36 and Short Musculoskeletal Function Assessment scores were not significantly different at each time interval, but a trend for improved function after primary arthrodesis compared with ORIF was noted. The primary arthrodesis group had better short-term and medium-term function.
In a review of 185 consecutive patients with Lisfranc injuries35, the overall infection rate was 4.3%. Pain was present in 30% of the patients. The number of tarsometatarsal injuries did not correlate to outcome. Increased reoperation rates were seen in patients with polytrauma, application of initial spanning external fixation, and associated ipsilateral cuboid and navicular injuries correlating with higher-energy mechanisms and injury patterns. Injuries treated with ORIF and those occurring in males were associated with worse mobility outcome subscores. Removal of prominent implants compared with implant retention positively affected bother outcome subscores but not any other functional measurements36. Pain and polytrauma were the greatest predictors of more dysfunction and worse bother subscores. Compared with normative data37, tarsometatarsal injuries have more long-term mobility but no other functional outcome impairment. Return-to-work status was excellent, with 91% returning to work and 42% being on their feet all day35. Of the patients who were unable to return to work, all had polytrauma and other injuries precluding them from working. If operative treatment of tarsometatarsal injuries was performed well, resulting in a stable, well-aligned foot and no prominent implants, the foot functioned well in the long term.
Cuboid and Navicular Fractures
The optimal management and outcome of cuboid fractures continues to be controversial. Historically, the cuboid was presumed to be protected between the calcaneus and the fourth and fifth metatarsal base38; therefore, surgical intervention was not necessary39. Displaced fractures with subluxation or dislocation were potentially treated with operative fixation to decrease convalescence time and improve functional results39. With marginal impaction, articular reconstruction with bone-grafting and ORIF could restore articular congruity40,41. In the event of cuboid fractures, the cuboid must be restored anatomically to properly gain lateral column length and foot alignment (Figs. 9-A and 9-B). Arthrodesis of the cuboid articulations produced less satisfactory results40.
In a comparison of operative and nonoperative treatment of ninety cuboid fractures, operative intervention was performed on subluxated or displaced fractures42. No difference was noted between groups with regard to complications, but the operative group had a higher rate of secondary surgery because of implant irritation. Associated navicular fractures correlated with changes to normal shoe wear and independently contributed to secondary osteoarthritis. The AO/OTA (Arbeitgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) fracture classification43 was not predictive of outcome. Reduction quality was associated with increased rates of posttraumatic osteoarthritis.
Navicular injuries consisting of a fracture or subluxation can be occult and result in a painful and problematic foot44. Despite poor subjective results, patients are able to perform many routine duties without disabling pain45. Most fractures had associated lateral column injuries requiring stabilization of both the medial and lateral columns46. Anatomical reduction is better achieved with ORIF47, and correction of the length and shape of the longitudinal arch of both the lateral and medial columns improves patient outcomes.
In a large series of ninety navicular fractures treated with or without surgery, patients with worse injury patterns—i.e., those with three or more associated foot injuries—had worse outcomes48. Patients with associated cuboid fracture patterns had increased rates of posttraumatic arthritis, pain, and need for custom shoe wear. Associated talar and tibial pilon injuries independently predicted the inability to return to work. Bone-grafting of fractures was associated with improved fracture reduction quality. Reduction quality was inversely related to pain, posttraumatic arthritis, and level of activity. Obese patients had higher rates of pain and posttraumatic arthritis and poorer maintenance of reduction quality. As with cuboid fractures, the AO/OTA fracture classification43 did not predict outcomes.
Navicular fractures are debilitating injuries that require restoration of medial column length and articular surface congruity. Reduction quality influences the development of posttraumatic arthritis in the long term. Pain, posttraumatic arthritis, and inability to wear normal shoes are related to inferior results. Present classification systems do not adequately predict outcome.
The midfoot is a complex anatomical association of many bones and articulations, restrained by an even more complex network of ligaments, capsules, and fascia, which must work in concert to provide normal and painless locomotion. The common eponyms of Lisfranc and Chopart refer to the distal and proximal joint relationships of the midfoot, respectively. An understanding of the essential joints in the midfoot, which require motion to be restored, and nonessential joints in the midfoot, which can be fused with impunity, guide the surgical tactic used to address these fractures. Careful diagnostic workup with three high-quality radiographs of the foot, weight-bearing when possible, and CT are used to detect associated injuries and fractures, and MRI is used to assess the Lisfranc ligament. Careful consideration should be given to the timing of surgery, as well as to the use of temporizing external fixation for the medial and/or lateral columns when these are shortened and severely fractured. After an appropriate waiting period, surgery is planned carefully to address each disrupted column with its corresponding tarsometatarsal and intertarsal joints. Treatment and rehabilitation should emphasize prevention of heel-cord contracture, which can amplify poor outcomes. Outcomes for these injuries should be measured, but good results have been associated even with grave injuries when anatomic reductions of all bones can be achieved with restoration of proper alignment. Such results are more likely to be achieved by the expert surgeon who has spent substantial time on the learning curve, given the rarity of the injury and the technical tricks necessary to accomplish successful results.
Wei
CJ;
Tsai
WC;
Tiu
CM;
Wu
HT;
Chiou
HJ;
Chang
CY. Systematic analysis of missed extremity fractures in emergency radiology. Acta Radiol.
2006 Sep;47(
7):710-7.[CrossRef]
Main
BJ;
Jowett
RL. Injuries of the midtarsal joint. J Bone Joint Surg Br.
1975 Feb;57(
1):89-97.
Mantas
JP;
Burks
RT. Lisfranc injuries in the athlete. Clin Sports Med.
1994 Oct;13(
4):719-30.
Curtis
MJ;
Myerson
M;
Szura
B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med.
1993 Jul-Aug;21(
4):497-502.[CrossRef]
Vuori
JP;
Aro
HT. Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma.
1993 Jul;35(
1):40-5.[CrossRef]
Elftman
H. The transverse tarsal joint and its control. Clin Orthop.
1960;16:41-6.[PubMed]
Myerson
MS;
Fisher
RT;
Burgess
AR;
Kenzora
JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle.
1986 Apr;6(
5):225-42.
Wiley
JJ. The mechanism of tarso-metatarsal joint injuries. J Bone Joint Surg Br.
1971 Aug;53(
3):474-82.
Hardcastle
PH;
Reschauer
R;
Kutscha-Lissberg
E;
Schoffmann
W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br.
1982;64(
3):349-56.[PubMed]
Myerson
MS;
McGarvey
WC;
Henderson
MR;
Hakim
J. Morbidity after crush injuries to the foot. J Orthop Trauma.
1994 Aug;8(
4):343-9.[CrossRef]
Pinzur
MS. Current concepts review: Charcot arthropathy of the foot and ankle. Foot Ankle Int.
2007 Aug;28(
8):952-9.[CrossRef]
van der Ven
A;
Chapman
CB;
Bowker
JH. Charcot neuroarthropathy of the foot and ankle. J Am Acad Orthop Surg.
2009 Sep;17(
9):562-71.
Quénu
E;
Küss
G. [Study on the dislocations of the metatarsal bones (tarsometatarsal dislocations) and diastasis between the 1st and 2nd metatarsal]. Rev Chir.
1909;39:281-336,.
Ross
G;
Cronin
R;
Hauzenblas
J;
Juliano
P. Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma.
1996;10(
2):119-22.[PubMed][CrossRef]
Trevino
SG;
Kodros
S. Controversies in tarsometatarsal injuries. Orthop Clin North Am.
1995 Apr;26(
2):229-38.
Arntz
CT;
Veith
RG;
Hansen
ST
Jr. Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg Am.
1988 Feb;70(
2):173-81.
Coss
HS;
Manos
RE;
Buoncristiani
A;
Mills
WJ. Abduction stress and AP weightbearing radiography of purely ligamentous injury in the tarsometatarsal joint. Foot Ankle Int.
1998 Aug;19(
8):537-41.
Raikin
SM;
Elias
I;
Dheer
S;
Besser
MP;
Morrison
WB;
Zoga
AC. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am.
2009 Apr;91(
4):892-9.[CrossRef]
Myerson
MS;
Cerrato
RA. Current management of tarsometatarsal injuries in the athlete. J Bone Joint Surg Am.
2008 Nov;90(
11):2522-33.
Nunley
JA;
Vertullo
CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med.
2002 Nov-Dec;30(
6):871-8.
Benirschke
SK;
Kramer
PA. High energy acute Lisfranc fractures and dislocations. Tech Foot Ankle Surg.
2010;9(
3):82-91.[CrossRef]
Hansen
ST. Functional reconstruction of the foot and ankle. Philadelphia: Lippincott Williams & Wilkins; 2000.
Sagi
HC;
Papp
S;
Dipasquale
T. The effect of suture pattern and tension on cutaneous blood flow as assessed by laser Doppler flowmetry in a pig model. J Orthop Trauma.
2008 Mar;22(
3):171-5.[CrossRef]
Bohay
DR;
Johnson
KD;
Manoli
A
2nd. The traumatic bunion. Foot Ankle Int.
1996 Jul;17(
7):383-7.
Manoli
A
2nd. Compartment syndromes of the foot: current concepts. Foot Ankle.
1990 Jun;10(
6):340-4.
Habbu
R;
Holthusen
SM;
Anderson
JG;
Bohay
DR. Operative correction of arch collapse with forefoot deformity: a retrospective analysis of outcomes. Foot Ankle Int.
2011 Aug;32(
8):764-73.[CrossRef]
DiGiovanni
CW;
Kuo
R;
Tejwani
N;
Price
R;
Hansen
ST
Jr;
Cziernecki
J;
Sangeorzan
BJ. Isolated gastrocnemius tightness. J Bone Joint Surg Am.
2002 Jun;84-A(
6):962-70.
Pinney
SJ;
Hansen
ST
Jr;
Sangeorzan
BJ. The effect on ankle dorsiflexion of gastrocnemius recession. Foot Ankle Int.
2002 Jan;23(
1):26-9.
Maskill
JD;
Bohay
DR;
Anderson
JG. Gastrocnemius recession to treat isolated foot pain. Foot Ankle Int.
2010 Jan;31(
1):19-23.[CrossRef]
Kuo
RS;
Tejwani
NC;
Digiovanni
CW;
Holt
SK;
Benirschke
SK;
Hansen
ST
Jr;
Sangeorzan
BJ. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg Am.
2000 Nov;82(
11):1609-18.
Mittlmeier
T;
Krowiorsch
R;
Brosinger
S;
Hudde
M. Gait function after fracture-dislocation of the midtarsal and/or tarsometatarsal joints. Clin Biomech (Bristol, Avon).
1997 Apr;12(
3):S16-S17.[CrossRef]
Coulibaly
MO;
Jones
CB;
Sietsema
DL;
Ringler
JR;
Endres
TJ. .
Ly
TV;
Coetzee
JC. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am.
2006 Mar;88(
3):514-20.[CrossRef]
Henning
JA;
Jones
CB;
Sietsema
DL;
Bohay
DR;
Anderson
JG. Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: a prospective randomized study. Foot Ankle Int.
2009 Oct;30(
10):913-22.[CrossRef]
Henning
J;
Jones
CB;
Sietsema
DL;
Anderson
JG;
Bohay
DR. .
Henning
JA;
Jones
CB;
Sietsema
DL;
Ringler
JR;
Endres
TJ;
Anderson
JG;
Bohay
DR. .
Hunsaker
FG;
Cioffi
DA;
Amadio
PC;
Wright
JG;
Caughlin
B. The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population. J Bone Joint Surg Am.
2002 Feb;84-A(
2):208-15.
McKeever
FM. Fractures of tarsal and metatarsal bones. Surg Gynecol Obstet.
1950 Jun;90(
6):735-45.
Hermel
MB;
Gershon-Cohen
J. The nutcracker fracture of the cuboid by indirect violence. Radiology.
1953 Jun;60(
6):850-4.
Sangeorzan
BJ;
Swiontkowski
MF. Displaced fractures of the cuboid. J Bone Joint Surg Br.
1990 May;72(
3):376-8.
Weber
M;
Locher
S. Reconstruction of the cuboid in compression fractures: short to midterm results in 12 patients. Foot Ankle Int.
2002 Nov;23(
11):1008-13.
Coulibaly
MO;
Jones
CB;
Sietsema
DL;
Ringler
JR;
Endres
TJ. .
Marsh
JL;
Slongo
TF;
Agel
J;
Broderick
JS;
Creevey
W;
DeCoster
TA;
Prokuski
L;
Sirkin
MS;
Ziran
B;
Henley
B;
Audigé
L. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma.
2007 Nov-Dec;21(
10 Suppl):S1-133.[CrossRef]
Eichenholtz
SN;
Levine
DB. Fractures of the tarsal navicular bone. Clin Orthop Relat Res.
1964 May-Jun;34:142-57.
Sangeorzan
BJ;
Benirschke
SK;
Mosca
V;
Mayo
KA;
Hansen
ST
Jr. Displaced intra-articular fractures of the tarsal navicular. J Bone Joint Surg Am.
1989 Dec;71(
10):1504-10.
Dhillon
MS;
Nagi
ON. Total dislocations of the navicular: are they ever isolated injuries?J Bone Joint Surg Br.
1999 Sep;81(
5):881-5.[CrossRef]
Richter
M;
Wippermann
B;
Krettek
C;
Schratt
HE;
Hufner
T;
Therman
H. Fractures and fracture dislocations of the midfoot: occurrence, causes and long-term results. Foot Ankle Int.
2001 May;22(
5):392-8.
Coulibaly
MO;
Jones
CB;
Sietsema
DL;
Ringler
JR;
Endres
TJ. .