Harlow Ethan R, Vakharia Ajit M, Alexeev Mikhail, Miskovsky Shana
Department of Orthopaedic Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
Sports Medicine Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
Video J Sports Med. 2022 Jan 18;2(1):26350254211055197. doi: 10.1177/26350254211055197. eCollection 2022 Jan-Feb.
Subtle Lisfranc injuries represent a primarily ligamentous Lisfranc complex injury involving the Lisfranc ligament and the medial and middle cuneiform ligaments. Static radiographic displacement or dynamic instability of the medial cuneiform and 2nd metatarsal typically warrants operative intervention to prevent chronic functional pain, allow for timely return-to-sport, and mitigate posttraumatic osteoarthritis. Flexible fixation techniques offer a unique solution to the issues seen with transarticular screws, plates, and arthrodesis for ligamentous Lisfranc injuries.
We present the case of a 16-year-old female basketball player with a subtle Lisfranc injury sustained during practice. X-rays show isolated widening of the 1st and 2nd metatarsal bases and dynamic diastasis between the medial and middle cuneiforms. Magnetic resonance imaging (MRI) confirmed a rupture of the plantar Lisfranc ligament. After extensive discussion regarding treatment options, the patient and her family decided to proceed with surgical intervention using a suture anchor and button technique to restore stability to the Lisfranc ligament and intercuneiform complexes.
A standardized dynamic examination under anesthesia identifies the extent of the injury. Exposure of the base of the 2nd metatarsal and medial cuneiform is performed. Reduction clamps are applied to restore the intercuneiform relationship and interval between the medial cuneiform and base of 2nd metatarsal. The suture anchor and button construct is placed using fluoroscopic guidance. A final dynamic examination is performed to confirm stability of the construct.
Biomechanical studies have shown that flexible fixation maintains physiologic motion about the Lisfranc articulations and has comparable stability to transarticular screws in cadaveric models of isolated Lisfranc ligament insufficiency. Clinical results are limited but demonstrate excellent postoperative functional outcome scores with very few fixation-related complications at 1 to 3 years.
Flexible fixation techniques for subtle Lisfranc injuries offer unique benefits to transarticular screws, plates, and arthrodesis. We highlight the appropriate evaluation of patients with a suspected subtle ligamentous Lisfranc injury, the surgical technique using a suture button and anchor construct, and review postoperative management and expected outcomes based on the present literature.
隐匿性Lisfranc损伤主要是指涉及Lisfranc韧带以及内侧和中间楔骨韧带的韧带性Lisfranc复合体损伤。内侧楔骨和第二跖骨的静态影像学移位或动态不稳定通常需要手术干预，以预防慢性功能性疼痛，使患者能够及时恢复运动，并减轻创伤后骨关节炎。对于韧带性Lisfranc损伤，柔性固定技术为经关节螺钉、钢板和关节融合术所带来的问题提供了独特的解决方案。
我们报告了一例16岁女性篮球运动员在训练中发生隐匿性Lisfranc损伤的病例。X线片显示第一和第二跖骨基底孤立性增宽，内侧和中间楔骨之间存在动态分离。磁共振成像（MRI）证实跖侧Lisfranc韧带断裂。在对治疗方案进行广泛讨论后，患者及其家属决定采用缝线锚钉和纽扣技术进行手术干预，以恢复Lisfranc韧带和楔骨间复合体的稳定性。
在麻醉下进行标准化的动态检查，以确定损伤程度。显露第二跖骨基底和内侧楔骨。应用复位夹以恢复楔骨间关系以及内侧楔骨与第二跖骨基底之间的间隙。在透视引导下放置缝线锚钉和纽扣结构。进行最后的动态检查以确认结构的稳定性。
生物力学研究表明，在孤立性Lisfranc韧带功能不全的尸体模型中，柔性固定可维持Lisfranc关节周围的生理运动，并且与经关节螺钉具有相当的稳定性。临床结果有限，但显示术后功能结局评分优异，在1至3年时固定相关并发症极少。
隐匿性Lisfranc损伤的柔性固定技术为经关节螺钉、钢板和关节融合术带来了独特的优势。我们强调对疑似隐匿性韧带性Lisfranc损伤患者的恰当评估、使用缝线纽扣和锚钉结构的手术技术，并根据现有文献回顾术后管理及预期结果。
