Imaging in Lisfranc injury: a systematic literature review

Sripanich, Yantarat; Weinberg, Maxwell; Krähenbühl, Nicola; Rungprai, Chamnanni; Mills, Megan; Saltzman, Charles L.; Barg, Alexej

doi:10.1007/s00256-019-03282-1

Cited by 58 publications

(49 citation statements)

References 47 publications

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“…To correct this flaw, it has been suggested that weight-bearing radiographs are used [3,7,9,15]. However, the problem with weight-bearing radiographs is that the severity of pain usually prevents the patients from reliably bearing weight, and therefore it is impossible to obtain reproducible images [50].…”

Section: Discussionmentioning

confidence: 99%

“…Primary diagnosis is usually based on non-weight-bearing radiographic imaging, though its sensitivity has been estimated to be quite low (24%–50%) when compared with CT [ 17 , 38 ] Weight-bearing radiographs or magnetic resonance imaging (MRI) are suggested modalities for detecting ligamentous injuries [ 33 , 36 – 38 ], yet it may be impossible to acquire weight-bearing images due to the extensively painful foot at the first presentation [ 33 , 36 – 38 , 40 , 53 ]. In their systematic review, Sripanich and colleagues [ 50 ] reported that CT scans seem to be currently the most precise imaging modality in detecting bony injuries; whereas, MRI seems to be the most precise in detecting ligamentous injuries. It has also been reported that the sensitivity of the weightbearing radiograph is not higher compared with the non-weight-bearing radiograph and is less sensitive than CT [ 38 ].…”

Section: Introductionmentioning

confidence: 99%

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Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries

Ponkilainen

Partio

Salonen

et al. 2020

Arch Orthop Trauma Surg

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Background Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter-or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury. Methods One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in onethird, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents. Results Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45-0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52-0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen's kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6-92.4) and specificity was 85.3% (52.9-100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003). Conclusions Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle. Level of evidence III.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries

Ponkilainen

Partio

Salonen

et al. 2020

Arch Orthop Trauma Surg

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“…In clinical settings where bilateral weightbearing CT scans are not regularly acquired, unilateral weightbearing CT scans may still allow an accurate evaluation of questionable displacement and resultant instability following various degrees of Lisfranc ligamentous injuries. A recent systematic review 41 suggested using bilateral weightbearing radiographs or nonweightbearing CT scans to investigate patients with a high clinical suspicion of injury presenting with normal nonweightbearing radiographic parameters. Specifically, using a unilateral parameter, a distance of more than 5 mm between the M1-M2 or the C1-M2 joint spaces has been considered an abnormal threshold for radiography, while for CT imaging, no validated threshold has been reported.…”

Section: Discussionmentioning

confidence: 99%

“…Images of this modality are free of overlapping structures, able to detect occult fractures, differentiate small avulsion fractures (fleck sign) from their mimics (ie, os intermetatarseum), and reveal minimal osseous subluxation around the tarsometatarsal (TMT) joints. 7,18,22,23 CT may also be preferred over magnetic resonance imaging (MRI), the superior modality to detect ligamentous abnormalities 6,19,35,40,41 ; the standard MRI cannot evaluate structures under weightbearing conditions, preventing investigators from drawing a confident correlation between the degree of injury in each aspect of the Lisfranc ligamentous complex (LLC) and its resultant instability.…”

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Change in the First Cuneiform–Second Metatarsal Distance After Simulated Ligamentous Lisfranc Injury Evaluated by Weightbearing CT Scans

et al. 2020

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Background: This study aimed to investigate the widening between the first cuneiform (C1) and second metatarsal (M2) in a Lisfranc ligamentous complex (LLC) joint injury model subjected to successive ligament dissections evaluated by weightbearing computed tomography (CT) scans. Methods: Twenty-four intact cadaveric feet served as the control (condition 1). Each component of the LLC (dorsal, interosseous, and plantar ligaments—conditions 2, 3, and 4, respectively) were then sequentially dissected. The specimens were equally randomized to 1 of 3 additional dissections (first or second tarsometatarsal [TMT] joint capsule or first-second intercuneiform ligament [ICL]—conditions 5a, 5b, and 5c, respectively). One additional ligament was then randomly transected (eg, condition 6ac—transection of the first TMT capsule and ICL). Finally, the remaining ligament was transected (condition 7). After each dissection, CT scans were acquired under nonweightbearing (NWB, 0 kg), partial-weightbearing (PWB, 40 kg), and full-weightbearing (FWB, 80 kg) conditions. The distance between the lateral border of C1 and the medial border of M2 was assessed to evaluate diastasis. Linear regressions with 95% CIs and converted q values were used to compare the measured data. Results: No significant differences were found within the control. In condition 4, an average axial plane widening relative to control of 1.6 mm (95% CI, 1.5-1.8) and 2.1 mm (95% CI, 1.9-2.2) was observed under PWB and FWB. A coronal plane widening of 1.5 mm (95% CI, 1.3-1.6) and 1.9 mm (95% CI, 1.7-2.1) under PWB and FWB, respectively, was measured. A 95% CI of at least a 2-mm widening during PWB was demonstrated in 5c, 6ac, 6bc, and 7. Conclusions: Weightbearing computed tomography (WBCT) scans were used to detect ligamentous Lisfranc injuries in a cadaveric model. Relative axial widening greater than 1.5 mm under PWB conditions could indicate a complete LLC injury. Complete transection of the intercuneiform 1-2 ligament was required to detect a 2-mm widening in the nonweightbearing condition. Clinical Relevance: This study provides insight on the detection of various severities of LLC injuries using WBCT imaging.

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Micro‐CT analysis of the Lisfranc complex reveals higher bone mineral density in dorsal compared to plantar regions

Requist

Sripanich

Rolvien

et al. 2021

Journal Orthopaedic Research

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Injuries to the Lisfranc complex may require surgical fixation, the stability of which may be correlated with bone mineral density (BMD). However, there is limited research on regional BMD variations in the Lisfranc complex. This study used quantitative micro-CT to characterize regional BMD in the four bones (medial cuneiform, intermediate cuneiform, first metatarsal, and second metatarsal) of this complex.Twenty-four cadaveric specimens were imaged with a calibration phantom using micro-CT. Each bone was segmented and divided into eight regions based on an anatomical coordinate system. BMD for each octant was calculated using scanspecific calibration equations and average image intensity. Differences between regions were analyzed using ANOVA with post hoc analysis and differences between groups of four octants in each plane were analyzed with t-tests with significance level α = 0.05. The highest density region in the medial cuneiform was the distal-dorsal-lateral and dorsal regions showed significantly higher BMD than plantar regions. The intermediate cuneiform had the highest density in the distal-dorsal-medial region and the dorsal and medial regions had higher BMD than the plantar and lateral regions, respectively. The densest region of the first metatarsal was the distal-dorsal-lateral and distal regions had significantly higher BMD than proximal regions. In the second metatarsal, the distal-dorsal-medial region had the highest density, and the distal, dorsal, and medial regions had significantly higher BMD than the proximal, plantar, and lateral regions, respectively. The predominant finding was a pattern of increased density in the dorsal bone regions, which may be relevant in the surgical management of Lisfranc injuries.

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Imaging in Lisfranc injury: a systematic literature review

Cited by 58 publications

References 47 publications

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries

Change in the First Cuneiform–Second Metatarsal Distance After Simulated Ligamentous Lisfranc Injury Evaluated by Weightbearing CT Scans

Micro‐CT analysis of the Lisfranc complex reveals higher bone mineral density in dorsal compared to plantar regions

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