SLR - July 2016 - Raymond Lee
Reference: Miyamoto W, Takao M, Innami K, Miki S, Matsushita T. Ligament Reconstruction with Single Bone Tunnel Technique for Chronic Symptomatic Subtle Injury of the Lisfranc Joint in Athletes. Arch Orthop Trauma Surg. 2015 Aug; 135(8): 1063-70.Scientific Literature Review
Reviewed By: Raymond Lee, DPM
Residency Program: Morristown Medical Center
Podiatric Relevance: This article introduces a novel surgical technique for treatment of chronic subtle injuries of the Lisfranc joint complex that had either failed to respond to initial treatment or those that were initially misdiagnosed. The authors discuss the definition of a chronic subtle injury of the Lisfranc joint to be essentially an initially undetected or poorly treated injury to the dorsal, interosseous and plantar tarsometatarsal ligaments resulting in chronic pain and inability to return to normal activity. They described that this can be evaluated for radiographically with findings including subtle diastasis with or without avulsion fragments between the medial cuneiform and second metatarsal base.
Although techniques have been previously described for treatment of acute injuries to these ligaments, the authors note that there has been no well-described surgical treatment for chronic Lisfranc injury cases where initial treatment or evaluation failed. They therefore hypothesized a novel technique utilizing a single bone tunnel from the second metatarsal base to the medial cuneiform with a gracilis tendon autograft as an appropriate technique for ligament reconstruction in athletic patients with chronic symptomatic subtle injury to the Lisfranc joint. The authors further pointed out that this technique may especially be more favorable than an arthrodesis of the Lisfranc joint in an athletic population, as they believe that controlled movement of the Lisfranc joint complex is important for proper return to preinjured activities in athletes.
Methods: Between April 2011 and October 2013, 5 athletes with mean age of 19.4 years were diagnosed with chronic subtle injury of the Lisfranc joint through radiographic and clinical diagnosis, and they underwent the described novel reconstructive operation with bone tunnel made between the medial cuneiform and second metatarsal bone, for near-anatomical reconstruction of the dorsal and interosseous ligaments. Three of the five athletes were initially diagnosed with injury of the Lisfranc joint and had conservative treatments (including cast immobilization with no weightbearing for several weeks follow by partial weightbearing) that had failed as they continued to have midfoot pain after they resumed their sports. One of the five patients was diagnosed with a midfoot sprain that had also failed conservative treatment, and one patient had failed to seek medical attention after the injury.
For the five patients, the mean interval from initial injury to reconstruction operative was 10.4 months, and patients were evaluated before and at 1 year after surgery using AOFAS scale for the ankle-midfoot. The results were then compared utilizing paired T-tests.
In regards to the operative technique, a gracilis tendon was harvested. Reduction of the Lisfranc joint complex was performed and a guide wire was then passed from the medial side of medial cuneiform to the base of the 2nd metatarsal bone, following the course of the tarsometatarsal ligaments. A bone tunnel was fabricated along this guidewire, and a 2-0 nylon loop was inserted into the bone tunnel using passing pin. At this point, the autograft was introduced into the bone tunnel through the 2-0 nylon loop, and the distal end of the autograft was pulled out from the bone tunnel and fixated utilizing a solid 4.0mm interference screw. The two ends of the autograft was tensioned and a suture anchor was inserted into the base of the second metatarsal bone perpendicularly to its long axis. Then the tensioned distal end of the autograft was fixed by suture anchor, and finally the tensioned ends of the autograft was sutured using 3-0 absorbable sutures.
Results: The mean duration of postoperative follow-up was 18.8 months. In the 5 patients, the mean AOFAS score improved significantly from 74.6 to 96 at 1 year after the operation. All patients were able to return to their previous athletic activities with no significant complications. Furthermore, the interval between surgery and return to athletic activity was 16.8 weeks.
In one patient, screw fixation was needed between the medial and middle cuneiforms because of significant instability. In all patients, full return to preinjury sports activities was achieved, and all patients felt confident in their results with no difficulties in performing their sport-specific drills.
Conclusions: The authors of this study effectively described a technique for Lisfranc ligament reconstruction utilizing a one bone tunnel for near anatomical reconstruction of the dorsal and interosseous ligaments with a lower risk of iatrogenic fractures. The authors cite two other studies (Nery et al and Hurano et al) that explored ligament reconstruction for acute subtle injuries, but each of these studies had their respective flaws—including increased risk for iatrogenic fractures or nondescriptive technical reports—and as such, the authors felt that their own novel technique allowed effective and reproducible results.
The authors do admit that their technique does not achieve true anatomical reconstruction of the Lisfranc complex as they only reconstruct the dorsal and interosseous ligaments, but as the dorsal and interosseous ligaments are the strongest ligaments of the joint complex, they should be suitable for restoration of function in the athletic population.
One interesting topic to explore is that the authors in this study used the gracilis tendon as their autograph. One of the cited studies, Nery et al., had described utilizing the third extensor digitorum longus tendon as a reconstructive substitute, and I believe that this could be a considerable replacement for the gracilis tendon as this would eliminate the need for making a separate proximal incision to for harvesting of the tendon.
Significant limitations of this study include its retrospective nature, short follow up period, lack of control studies as well as its limited number of patients. Nevertheless, it brings forth an interesting novel technique for treatment of chronic subtle injury of the Lisfranc joint complex in the athletic population. Because chronic subtle injury of the Lisfranc joint complex is relatively rare in the general population, I believe that this article was effective in increasing awareness about these cases and reminding practitioners of the possible diagnosis in patients suffering from chronic midfoot pain.