Treatment of Pediatric Lisfranc Injuries: A Systematic Review and Introduction of a Novel Treatment Algorithm

Samuel Paek1† and Grant D. Hogue2,3

¹Geisinger Commonwealth School of Medicine, Scranton, PA 18509 ²Harvard Medical School, Boston, MA 02115 ³Orthopedic Department at Boston Children’s Hospital, Boston, MA 02115 †Doctor of Medicine Program Correspondence: spaek@som.geisinger.edu

Abstract

Background: Pediatric Lisfranc injuries (PLI) are rare injuries that have few studies published about their occurrence and treatment in pediatric populations. Due to this lack of information, the diagnostic criteria and surgical or non-surgical methods for treatment have not been clearly established within the pediatric orthopedic literature. The objective of this study was to review the published literature related to treatment options for PLI in order to develop a concise stepwise treatment algorithm for pediatric patients presenting with Lisfranc injuries. Methods: A systematic literature review was conducted using PubMed to find studies reporting treatment of PLI with followup of long-term outcomes. Data collection involved the number of feet treated, primary diagnostic method, treatment methods employed, and reported post-treatment complications. Results: Ten articles reporting on 114 Lisfranc injuries treated were found. In summation, 42% (49/115) of feet were treated with open reduction internal fixation (ORIF) using Kirschner wires (K-wires) and/or screws, 29% (33/115) required no reduction, 17% (20/115) using cast immobilization, 5% (6/115) using closed reduction, 3% (4/115) using suture button fixation, and 3% (3/115) with percutaneous fixation.

Conclusion: There were two main limitations to this study. First, there are few published studies with longitudinal outcomes of PLI treatment. Second, some case series did not disclose which procedure a patient with post-treatment complications underwent. Therefore, an overall analysis of success and failure rates with associated complications of each procedure could not be conducted. In conclusion, we found that a stepwise approach to evaluating conservative and surgical treatment options based on the presentation of the PLI should be utilized to optimize long-term outcomes.

Introduction

Pediatric Lisfranc injuries (PLI) are an uncommon injury of the tarsometatarsal (TMT) joint complex that primarily affects the first and second metatarsals (MT) and their connection to the medial and middle cuneiforms but can also have effects across the entirety of the TMT joint. The instability of this joint complex can be attributed to the absence of a stabilizing ligament between the first and second MTs. The mechanism of injury for PLI is commonly caused by axial loading in a plantarflexed foot position due to disruption of the Lisfranc ligament’s connection between the proximal base of the second MT to the medial cuneiform (1). Due to the rarity of published literature on this injury in pediatric cases, evidence-based treatment guidelines for PLI are limited. This contrasts with adult Lisfranc injuries, which have standardized treatment protocols and less variability in their management due to the closure of physeal growth plates. This is an important area of concern when considering surgical versus non-surgical options for Salter-Harris type fractures because exposure of the physes or joint surface during operative management may induce premature physeal closure and/or fusion as a result (7, 18). Furthermore, the intraarticular nature of PLI increases the risk of developing posttraumatic degenerative arthritic changes in the TMT joint complex (19). Bone deformities of the midfoot region can develop during remodeling from physeal involvement which can create further complications for the patient (7, 18). There are many treatment options with varying outcomes, but no consensus on the most optimal management protocol for this injury (1, 2, 4–7, 8–11, 13). Nonetheless, the majority of studies included in this systematic review have achieved successful post-operative outcomes using surgical intervention to achieve reduction and fixation in treating PLI (2, 4–7, 8–11, 13). The purpose of this study is to define standardized diagnostic criteria and novel treatment guidelines based on the classification of injury to pair the best management protocols with optimal long-term outcomes for future patients receiving treatment for PLI.

Methods

Search strategy A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) research methods and reporting guidelines (3). A digital search of the online medical literature database MEDLINE (PubMed) was done between January 4, 2021, and January 18, 2021. The search strategy included the following keyword terms: “pediatric” OR “adolescent” OR “child” AND “lisfranc” OR “tarsometatarsal.” All potential studies were stored to Zotero (zotero.org), an open-source software program used for bibliographic citation management, to facilitate evaluation of the studies used.

Study selection The published literature selected for this study involves therapeutic measures for PLI. Studies involving adult-only cases were excluded. Studies that included a mixture of pediatric and adult cases, but that did not distinguish data extracted from pediatric and adult patients were excluded. Case reports without appropriate post-operative follow-up were excluded. Studies involving cadaveric specimens were excluded. Studies published in languages other than English were excluded.

Figure 1. Flow chart of literature search identifying articles screened, assessed, included, and excluded

Data extraction

Ten studies met criteria for an in-depth review. These articles were examined for the number of patients/feet included in the study, diagnostic indicators for PLI including imaging and physical exam findings, the number of patients undergoing either surgical or non-surgical therapy, instrumentation used (if applicable), and their respective outcomes. Each outcome was taken into consideration when determining the novel treatment guidelines. A PLI was determined resolved if there was complete resolution of pain and restored function of the foot. A PLI was determined to have a failure of resolution if there were posttreatment complications involving either pain, instrumentation malfunction (if applicable), or impaired function. Possible biases were considered when extracting data from case series studies and limitations were noted. Some case series studies did not differentiate which treatment option a patient had undergone even if they had a resultant complication; thus, the sum of complications for each specific treatment option was unable to be obtained from the case series studies.

Results

There were 290 articles identified via a PubMed search. Duplicate articles identified through other sources and articles written in languages other than English were excluded. The remaining total articles were screened based on their titles, leaving 46 total full-text articles to be assessed for eligibility using the previously defined criteria. Papers were excluded if they only included studies with adult patients, did not have post-operative follow-up, involved treatments for non-PLI, or included cadaveric studies. This left a total of 10 full text studies (2, 4–11, 13) to be used in qualitative synthesis for this systematic review. Figure 1 details this search and selection process for narrowing the initial 290 searched articles to the 10 full-text studies used in this systematic review. There were five PLI included from case reports and 109 feet from case series studies that summated to a total amount of ‘114’ feet included in the data from the 10 studies. One foot from a case report (7) was treated with both closed reduction and ORIF, bringing the total number of treatment procedures performed on feet to 115. Treatment methods were as follows: 43% (49/115) open reduction internal fixation (ORIF) with K-wires and/or screws, 29% (33/115) did not require reduction, 17% (20/115) with cast immobilization, 5% (6/115) closed reduction, 3% (4/115) suture button non-rigid fixation, and 3% (3/115) with percutaneous fixation. A summary of diagnostic imaging, treatment methods, and post-treatment complications are summarized for case reports in Table 1 and case series studies in Table 2. Buoncristiani (8) saw eight patients with a mean age of 6.6 years with an age range of 3 to 13 years old at the time of evaluation. The symptomatic presentation included tenderness over the TMT joint complex and mild foot edema in all patients; six of them also had ecchymosis over the dorsal midfoot.

Table 1. Summary of diagnostic tools, therapies performed, and outcomes from single case report studies.

Table 2. Summary of diagnostic tools, therapies performed, and outcomes from case series studies.

Each patient had initial radiographs that were taken, which revealed fractures of metatarsals and cuneiforms, cuneiform avulsion, or negative radiograph interpretations. All eight patients were treated non-operatively with a short leg walking cast and followed at 3- and 6-week intervals. Immobilization ranged from 3 to 7 weeks and was discontinued after the patients had resolution of pain at the TMT joint complex and were able to ambulate without complications. Final radiographs were taken at their last follow-up, which averaged 32 months. Seven out of eight patients treated using the SLWC had complete resolution of their foot pain at rest and during physical activity. Radiographs confirmed healing of the injury and revealed maintenance of the TMT joint complex. These seven patients had a midfoot functional rating (MFR) of 100. One out of the eight patients continued to have “nonlimiting” midfoot pain and edema after 5 minutes of physical activity but absent at rest; no pain medication management required; and a MFR of 87. This patient’s physical examination of the TMT joint complex was benign, and tenderness was not reproduced with palpation or pronation-abduction stress. The radiograph revealed a healed cuneiform fracture, but also had residual narrowing of joint space consistent with posttraumatic degenerative joint disease in the TMT joint complex. Veijola (9) saw seven patients with a mean age of 14.7 years with an age range of 13 to 16 years old at the time of evaluation. Symptomatic presentation of six patients included edema of the foot and one patient with erythema of the foot. All patients had an initial radiograph taken, which revealed Lisfranc dislocations in all seven patients, and three patients had a computerized tomography (CT) image taken prior to beginning operative treatment. All seven patients underwent ORIF using cannulated screws and K-wires within 24 hours to 7 days after the initial injury. Patients had the respective foot immobilized for an average of 5 weeks and hardware removal at a range of 3 to 7 weeks and an average of 5 weeks after the operation. Post-operative radiographs graded anatomic reduction as “excellent” in six patients and “good” in one patient. However, radiographs taken during outpatient follow-up of two patients with “excellent” grade postoperative anatomic reduction were graded as having “slight” degenerative changes. With regards to functional outcomes, three patients reduced their baseline activity level, and two patients were unable to participate in the same activities as prior to their injury. A possible limiting factor of this study is that the two patient cases with “slight” degenerative changes did not have their post-operative cast immobilization times recorded. Hill (10) conducted a retrospective review of 56 patient cases treated for PLI from 2003 to 2014 with an average age of 14.2; the age range was not provided. 59% (33/56) of patients did not require anatomic reduction to treat their injury; this cohort consisted of 52% (17/33) ligamentous Lisfranc injuries and 48% (16/33) Lisfranc fracture injuries. 9% (5/56) of patients were treated by closed anatomic reduction which included a short leg cast and/or air boot cast; this cohort consisted of 100% (5/5) Lisfranc fracture injuries. 32% (18/56) of patients required ORIF treatment to correct their injuries; this cohort consisted of 100% (18/18) Lisfranc fracture injuries. Of the patients with Lisfranc fractures, 26% (10/39) had physeal involvement. From this cohort, three patients underwent ORIF, five patients were managed with closed reduction and castings, and two patients did not require reduction. It is also worth noting that from the patients with Lisfranc fractures, 51% (20/39) of them were treated non-operatively. All patients were followed during a range of 11 to 30 weeks with an average of 19.5 weeks to evaluate their recovery and ability to weight bear. The average time to weight bear as tolerated differed significantly between patients who incurred fractures, 14.5 weeks, compared to those who received conservative management, 6.5 weeks. Two specific patients incurred posttraumatic changes due to the severity of damage to their Lisfranc joint complex. One patient with a complete displacement of the first MT Salter-Harris fracture had physeal arrest at age 12 and the other with a severely displaced Lisfranc joint complex had unresolved pain with weight-bearing due to a broken pin that remained in his cuboid. Patients with closed physes were more likely to be selected for operative management compared to patients with open physes. Cheow (11) conducted a retrospective study of eight patients with a mean age of 13.6 years that were treated between 2009 to 2014 and had post-operative follow-up for greater than 12 months, with a mean duration of 3.8 years. Symptomatic presentation of all eight patients included tenderness and edema of the feet examined: neurovascularly intact. All patients were treated within 7 days of their injury onset. Three out of eight patients underwent closed reduction, with two patients undergoing screw fixation and one patient undergoing K-wire fixation. Five out of eight patients underwent ORIF, with three patients undergoing screw fixation and two patients undergoing K-wire fixation. The average time of hardware removal was 3 to 5 months for screw fixation and 4 to 5 weeks for K-wire fixation. The average time to return to full weight-bearing was 3 months in all patients. Post-operative complications were observed in four patients. One out of those four patients had an inadequately maintained anatomic reduction after undergoing ORIF using K-wires, despite being non-weight bearing before hardware removal, and continued to have mild intermittent foot pain. Another of those four patients revealed an appropriately maintained closed screw reduction during his 6-year follow-up examination but had screw breakage that was left in situ which was the suspected cause of his daily moderate foot pain. Screw breakage has been attributed to premature weight bearing on the injured foot before hardware removal took place that was also observed in another patient; however, this patient did not report midfoot pain during follow-up evaluations. These two out of four patients with screw breakages observed in follow-up imaging were reported to have initiated weight bearing before removal of implants. The last of those four patients with postoperative complications had closed screw fixation with loss of anatomic reduction. This may be attributed to the failure of the screw to reach across the Lisfranc joint in this patient that was seen in her post-operative radiograph. Subsequent imaging done after 6 months revealed an intermetatarsal distance between the first and second MT of 3.49 mm. Appropriate distance between the first and second MT should be less than 3 mm and was specifically measured to have a median distance of 1.0 mm for a child of this patient’s age (13 years old) (12).

A limiting factor of this study is the lack of information detailing time to partially weight bear and compliance with weightbearing before hardware removal as this may have caused some of the postoperative complications seen. The presence or absence of posttraumatic degenerative changes was also not discussed in the interpretations of radiographs taken at each patient’s follow-up examination. Kushare (13) conducted a retrospective study of 30 patients with an average age of 13.6 years, with a range of 8 to 17 years) and an average follow-up time of 36 weeks. Symptomatic presentation of all patients included tenderness and edema of the midfoot, and ecchymosis in 13 cases. All patients were screened using radiographs, but only five patients did not have further imaging. Twenty-five patients received CT or magnetic resonance imaging (MRI) to confirm or further examine their injuries; two cases required MRI due to negative radiographs. Sixty-one percent (19/30) of patients were managed operatively with screw fixation being used in 14 cases, interosseous suture-button technique fixation being used in three cases, and K-wire fixation being used in two cases. Hardware removal occurred on an average of 28.5 days with a range of 6 to 65 days. Surgical indications included >2 mm displacement or diagnoses of avulsion fractures on radiographs, CT, or MRI. Post-operative follow-up examinations averaged 36 weeks with a range of 12 to 176 weeks. Patients with the suture-button fixation did not require additional surgery for hardware removal. 31% (11/30) patients were managed conservatively for non-displaced injuries using a short leg cast (8/11) or CAM boot (3/11) and given instructions to limit weight-bearing. Indications for conservative management were non-displaced Lisfranc injuries. The only post-treatment complication reported was a patient that developed was an Achilles tendon contracture and was managed with physical therapy. There were no cases that reported broken hardware or implants left in situ. There were no obvious differences in the outcome of treatment if it took place less than 4 weeks of injury onset. Additionally, there were no significant differences in the demographics, clinical presentation, or treatment outcomes between the patients treated surgically and conservatively. A possible limitation of this study is the absence of details outlining the medical rationale for the selected method of treatments in patients even after accounting for the lack of significant differences in presentation. The summary of all results with the number of feet treated, diagnostic imaging used, treatment methods, and posttreatment complications are outlined in Tables 1 and 2. 42% (49/115) of feet were treated with ORIF using K-wires and/ or screws, 29% (33/115) required no reduction, 17% (20/115) using cast immobilization, 5% (6/115) using closed reduction, 3% (4/115) using suture button fixation, and 3% (3/115) with percutaneous fixation using K-wires and/or screws.

Discussion

Currently, there is no literature with an agreed upon consensus for the best method to treat PLI, due to a shortage of papers discussing the diagnosis, treatment options, and long-term outcomes (1). This is in part due to the rarity of its presentation

in orthopedic settings and difficulty of diagnosis, as it is often missed (1, 10, 13). Differing opinions on treatment management are employed at different orthopedic centers and may further contribute to the lack of consensus (8-11, 13). However, synthesizing the information seen across the included studies has allowed us to generate a stepwise diagnostic and treatment algorithm for PLI that is outlined in Figure 2. Understanding the risks and benefits associated with initiating surgical intervention as the primary treatment modality should be carefully considered due to the increased risk for adverse longterm outcomes such as posttraumatic osteoarthritis associated with intraarticular Lisfranc injuries (7, 19). Nonetheless, the primary aim of treatment should be to maintain an anatomic reduction of less than 2 mm to preserve the best long-term functional outcome for the patient. When including PLI as a possible differential diagnosis, two points of reference that must be included are physical exam findings and weight-bearing radiographs (18). PLI involving the TMT joint complex typically manifests with midfoot pain, swelling, decreased ability to weight bear, and plantar ecchymosis on physical exam (20, 21). Initial weight-bearing radiographs should be taken of both the injured and non-injured foot to have a baseline comparison. If radiographs reveal a distance greater than 2.0 mm between the first and second MTs or between the medial cuneiform and proximal base of second MT, loss of alignment between the second MT and the middle cuneiform, Fleck sign indicating avulsion within the Lisfranc joint complex, diastasis and/or instability of the Lisfranc joint complex may be present (1, 13, 23). If weightbearing radiographs are inconclusive, advanced imaging is the next appropriate step using CT first and if necessary, a subsequent MRI. CT is chosen first because of its superior ability to detect non-displaced fractures, avulsion fractures, and minimal osseous subluxations (24). A systematic review that surveyed diagnostic imaging for Lisfranc injuries revealed that CTs diagnosed up to 60% more MT fractures, double the number of tarsal fractures and joint malalignments compared to plain radiographs (24). If both non-weight-bearing radiographs and CT are inconclusive, then an MRI is used for its accuracy in detecting ligamentous injuries. After diagnosis, conservative treatment should be considered if the PLI reveals displacement of less than 2.0 mm and maintains a stable Lisfranc joint complex (12). Kushare (13) found that there was no significant difference between clinical presentations and outcomes of patients with PLI treated surgically and conservatively. Positive outcomes were reported in patients who had received delayed treatment up to 4 weeks from injury onset, compared to those who received treatment shortly afterward. From this cohort, post-treatment surveys revealed that positive outcomes were consistent with patients receiving delayed treatment up to 4 weeks from injury onset. Therefore, our algorithm suggests initial conservative management with follow-up radiographs to evaluate the degree of displacement as a viable option by immobilization and limited weight bearing using a short leg walking cast or controlled ankle motion boot for 6 weeks (6, 8, 13). Length of immobilization may vary between patients depending on adherence to weight-bearing guidelines provided by the surgeon, which may range from 11 to 14 weeks for surgically treated PLI and up to 7 weeks for conservatively treated PLI. Surgical intervention has been used for PLI as a primary treatment modality for PLI but given our study’s findings we believe it should be used as the primary treatment only if the Lisfranc joint is unstable due to disruption of the Lisfranc ligament, has displacement greater than 2.0 mm, or if the patient has closed physes (1, 7, 8, 10). Surgeons should avoid large subperiosteal dissections and unnecessarily exposing open physes, because this may induce premature physeal closure and joint fusion as a result, leading to posttraumatic osteoarthritis and impaired function (7, 10, 25, 26). A surgical alternative to rigid hardware fixation using the suture-button technique has emerged with excellent results in adults and pediatric patients (2, 7, 27). Tzatzairis (2) and Kushare (13) published a case report and case series study, respectively, documenting the successful treatment of a PLI using the suture button technique, also known as the TightRopeTM Syndesmosis Device, to maintain non-rigid fixation across the Lisfranc joint. An adult case series study specifically focusing on suture-button fixation revealed exceptional outcomes (27). Advantages with this technique include increased healing that was shown through earlier time to full weight-bearing without requiring a cast at 6 weeks post-operatively and lack of a second procedure for hardware removal. Earlier weight-bearing and mobilization may be attributed to enhanced healing from the non-rigid fixation; all patients were reported returning to full weight-bearing status without requiring a cast by 6 weeks (27). A cadaveric study using the suture-button technique across the Lisfranc joint found evidence of similar stability as screw fixation (22), reaffirming the original goal of maintained anatomic reduction. This has potentially more promising long-term outcomes and decreased risks than rigid fixation with screws such as the risk for screw breakage, prolonged decreased range of motion affecting healing, cartilage damage, and a second procedure requiring screw removal (14). Additional studies are required to increase the generalizable efficacy of these results in treating PLI before a conclusion can be made.

Conclusion

The results and analysis of this systematic literature review are subject to limitations of retrospective review, varying and sometimes short follow-up periods (months compared to years), small sample size, non-randomized selection, and inconsistent patient adherence to prescribed weight limiting status. To truly determine the efficacy of each treatment modality available, a randomized controlled study is necessary with an appropriately sized sample pool to assess the viability of each option. The goal of this study is to create guidelines for the treatment of PLI using the currently available literature based on the published data from many orthopedic centers. A stepwise treatment algorithm was created using the evidence cited from this study is available for surgeons to use in Figure 2 when considering both non-surgical and surgical options. We believe that initial treatment should include conservative options with appropriate follow-up to assess the healing of the PLI before surgical treatment is initiated.

Disclosures

None declared.

References

1. Halai M, Jamal B, Rea P, Qureshi M, Pillai A. Acute fractures of the pediatric foot and ankle. World J Pediatr. 2015;11(1):14–20. 2. Tzatzairis T, Firth G, Parker L. Adolescent Lisfranc injury treated with TightRopeTM: A case report and review of literature. World J Orthop. 2019;10(2):115–22. 3. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC,

Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339(jul21 1):b2700. 4. Della Valle CJ, Su E, Nihal A, Rosenberg ZS, Trepman E:

Acute disruption of the tarsometatarsal (Lisfranc’s) joints in a ballet dancer. J Dance Med Sci 2000;4:128-131. 5. Carrasco A, Perez C, Caminero F. Lisfranc injury in a 14-year-old patient. A case report and literature review.

Arch Clin Exp Surg. 2019;(0):1. 6. Kriz P, Rafferty J, Evangelista P, Van Valkenburg S,

DiGiovanni C. Stress fracture of the second metatarsal and sprain of lisfranc joint in a pre-professional ballet dancer.

J Dance Med Sci. 2015;19(2):80–5. 7. Lesko G, Altman K, Hogue G. Midfoot degenerative arthritis and partial fusion after pediatric Lisfranc fracture-dislocation. J Am Acad Orthop Surg Glob Res Rev. 2018;2(3):e004. 8. Buoncristiani AM, Manos RE, Mills WJ. Plantar-flexion tarsometatarsal joint injuries in children. J Pediatr Orthop. 2001;21(3):324–7. 9. Veijola K, Laine H-J, Pajulo O. Lisfranc injury in adolescents.

Eur J Pediatr Surg. 2013;23(4):297–303. 10. Hill JF, Heyworth BE, Lierhaus A, Kocher MS, Mahan ST.

Lisfranc injuries in children and adolescents. J Pediatr

Orthop B. 2017;26(2):159–63. 11. Cheow X, Lam KY. Midterm functional outcomes in operatively treated adolescent Lisfranc injuries. J Pediatr

Orthop B. 2018;27(5):435–42. 12. Knijnenberg LM, Dingemans SA, Terra MP, Struijs PAA,

Schep NWL, Schepers T. Radiographic anatomy of the pediatric Lisfranc joint. J Pediatr Orthop. 2018;38(10):510–3. 13. Kushare I, Wunderlich N, Elabd A, Attia E. Pediatric and adolescent Lisfranc injuries - Presentation, treatment and outcomes. Foot (Edinb). 2021;46(101737):101737. 14. Bansal A, Carlson DA, Owen JR, Cheatham SA, Williams

DSB 3rd, Kates SL, et al. Ligamentous Lisfranc injury: A biomechanical comparison of dorsal plate fixation and transarticular screws: A biomechanical comparison of dorsal plate fixation and transarticular screws. J Orthop

Trauma. 2019;33(7):e270–5. 15. Mayr JM, Seebacher U, Lawrenz K, Pesendorfer P,

Berghold A, Baradaran S. Bunk beds--a still underestimated risk for accidents in childhood? Eur J Pediatr. 2000;159(6):440–3. 16. Wiley JJ. The mechanism of tarso-metatarsal joint injuries.

J Bone Joint Surg Br. 1971;53-B(3):474–82. 17. Rosendahl K, Strouse PJ. Sports injury of the pediatric musculoskeletal system. Radiol Med. 2016;121(5):431–41. 18. Denning JR. Complications of pediatric foot and ankle fractures. Orthop Clin North Am. 2017;48(1):59–70. 19. Thomas AC, Hubbard-Turner T, Wikstrom EA, Palmieri-

Smith RM. Epidemiology of posttraumatic osteoarthritis.

J Athl Train. 2017;52(6):491–6. 20. Pommering TL, Kluchurosky L, Hall SL. Ankle and foot injuries in pediatric and adult athletes. Prim Care. 2005;32(1):133–61. 21. Ross G, Cronin R, Hauzenblas J, Juliano P. Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma. 1996;10(2):119–22. 22. Panchbhavi VK, Vallurupalli S, Yang J, Andersen CR. Screw fixation compared with suture-button fixation of isolated Lisfranc ligament injuries. J Bone Joint Surg Am. 2009;91(5):1143–8. 23. Grewal US, Onubogu K, Southgate C, Dhinsa BS. Lisfranc injury: A review and simplified treatment algorithm. Foot (Edinb). 2020;45(101719):101719. 24. Sripanich Y, Weinberg MW, Krähenbühl N, Rungprai

C, Mills MK, Saltzman CL, et al. Imaging in Lisfranc injury: a systematic literature review. Skeletal Radiol. 2020;49(1):31–53. 25. Dubois-Ferrière V, Lübbeke A, Chowdhary A, Stern R,

Dominguez D, Assal M. Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries. J Bone

Joint Surg Am. 2016;98(9):713–20. 26. Marín-Peña OR, Viloria Recio F, Sanz Gómez T, Larrainzar

Garijo R. Fourteen years follow up after Lisfranc fracturedislocation: functional and radiological results. Injury. 2012;43 Suppl 2:S79-82. 27. Brin YS, Nyska M, Kish B. Lisfranc injury repair with the

TightRopeTM device: A short-term case series. Foot Ankle

Int. 2010;31(7):624–7.