SLR - July 2015 - Ryan Kish

Ligament Reconstruction with Single Bone Tunnel Technique for Chronic Symptomatic Subtle Injury of the Lisfranc Joint in Athletes

Reference: Wataru M, Masato T, Ken I, Shinya M, Takashi M. Ligament reconstruction with single bone tunnel technique for chronic symptomatic subtle injury of the Lisfranc joint in athletes. Arch Orthop Trauma Surg. 2015 May 28. [Epub ahead of print].

Scientific Literature Review

Reviewed By: Ryan Kish, DPM
Residency Program: Detroit Medical Center

Podiatric Relevance: There are few procedures reported for reconstruction of the Lisfranc ligaments in subtle injuries. These subtle injuries can often result in continued pain and absence from athletic activity if not appropriately managed or recognized in the acute injury period. The authors report a novel technique for reconstruction utiVlizing a single bone tunnel with autologous gracilis tendon graft in a series of five athletes.

Methods: Between 2011-2013, five athletes (four male, one female) with mean age of 19.4 years were diagnosed with chronic subtle injury of the Lisfranc joint and underwent reconstructive surgery.  Diagnosis was made through physical examination and plain film radiographs. The mean interval from the initial injury to surgery was 10.4 (range 5–24) months. All patients were evaluated with the AOFAS midfoot-ankle score preoperatively and at one year post operatively.  Operative technique included harvesting approximately 12cm of the ipsilateral gracilis tendon.  Skin incisions were created dorsally between the base of the 1st and 2nd metatarsals as well as the medial aspect of the medial cuneiform. Reduction was accomplished with a large bone reduction forceps.  A bone tunnel was created from the medial cuneiform to the 2nd metatarsal and the tendon autograft was passed through. The graft was secured proximally with an interference screw and distally with an anchor. Patients were kept non-weightbearing for 6 weeks.

Results: Mean postoperative follow-up period was 18.8 (range 12–26) months. Mean AOFAS score improved significantly from 74.6 ± 2.5 (range 71–77) preoperatively to 96.0 ± 5.5 (range 90–100) 1 year postoperatively (p < 0.01). All patients were able to return to their previous athletic activities, and the mean interval between the operation and return to athletic activity was 16.8 ± 1.1 (range 15–18) weeks. No complications were encountered.

Conclusion: The authors of this study concluded that their method for Lisfranc ligament reconstruction is effective for athletes with chronic subtle injury despite limitations in their study design. Operative intervention is indicated in acute unstable Lisfranc injuries, especially in the high demand athlete.  In the high demand athlete, reconstruction of the Lisfranc ligament may be preferable to arthrodesis as this may result in a loss of motion in the medial and central column of the TMT joint. This method of reconstruction appears promising, as it nearly recreates the anatomic Lisfranc ligament and is securely fixated. Harvesting an autologous graft has the advantages of biocompatibility and cost, but donor site morbidity has to be taken into account. Further research is needed before this method can be established as the standard of care for treatment of subtle unstable Lisfranc injuries.

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