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

Steven M. Raikin, Ilan Elias, Sachin Dheer, Marcus Peter Besser, William B. Morrison, Adam C. Zoga

Research output: Contribution to journalArticle

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Abstract

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 conventionalmagnetic 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 onmagnetic 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. Level of Evidence: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Original languageEnglish (US)
Pages (from-to)892-899
Number of pages8
JournalJournal of Bone and Joint Surgery - Series A
Volume91
Issue number4
DOIs
StatePublished - Apr 1 2009

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Ligaments
Metatarsal Bones
Magnetic Resonance Imaging
Wounds and Injuries
Joints
Joint Instability
Anesthesia
Sprains and Strains
Documentation
Rupture
Magnetic Resonance Spectroscopy
Logistic Models
Sensitivity and Specificity
Plantar Plate

All Science Journal Classification (ASJC) codes

  • Surgery
  • Orthopedics and Sports Medicine

Cite this

@article{ee2d3aa9ca9549c2ae10f75a3b26bee4,
title = "Prediction of midfoot instability in the subtle Lisfranc injury: Comparison of magnetic resonance imaging with intraoperative findings",
abstract = "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 conventionalmagnetic 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 onmagnetic 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. Level of Evidence: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.",
author = "Raikin, {Steven M.} and Ilan Elias and Sachin Dheer and Besser, {Marcus Peter} and Morrison, {William B.} and Zoga, {Adam C.}",
year = "2009",
month = "4",
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}

Prediction of midfoot instability in the subtle Lisfranc injury : Comparison of magnetic resonance imaging with intraoperative findings. / Raikin, Steven M.; Elias, Ilan; Dheer, Sachin; Besser, Marcus Peter; Morrison, William B.; Zoga, Adam C.

In: Journal of Bone and Joint Surgery - Series A, Vol. 91, No. 4, 01.04.2009, p. 892-899.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Prediction of midfoot instability in the subtle Lisfranc injury

T2 - Comparison of magnetic resonance imaging with intraoperative findings

AU - Raikin, Steven M.

AU - Elias, Ilan

AU - Dheer, Sachin

AU - Besser, Marcus Peter

AU - Morrison, William B.

AU - Zoga, Adam C.

PY - 2009/4/1

Y1 - 2009/4/1

N2 - 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 conventionalmagnetic 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 onmagnetic 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. Level of Evidence: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

AB - 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 conventionalmagnetic 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 onmagnetic 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. Level of Evidence: Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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