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Inconsistent radiographic diagnostic criteria for lisfranc injuries: a systematic review

BMC Musculoskeletal Disorders volume 24, Article number: 915 (2023) Cite this article

Abstract

Purpose

To evaluate the radiographic diagnostic criteria and propose standardised radiographic criteria for Lisfranc injuries.

Methods

A systematic review of the PubMed and Embase databases was performed according to the PRISMA guidelines. The various radiographic criteria for the diagnosis of Lisfranc injuries were extracted. Descriptive statistics were presented for all continuous (as mean ± standard deviation) and categorical variables (as frequencies by percentages).

Results

The literature search included 29 studies that totalled 1115 Lisfranc injuries. The risk of bias ranged from “Low” to “Moderate” risk according to the ROBINS-I tool. The overall recommendations according to the GRADE assessment ranged from “Very Low” to “High”. 1st metatarsal to 2nd metatarsal diastasis was the most common of the 12 various radiographic diagnostic criteria observed, as was employed in 18 studies. This was followed by 2nd cuneiform to 2nd metatarsal subluxation, as was employed in 11 studies.

Conclusion

The radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. The proposition for homogenous radiographic diagnostic criteria is that the following features must be observed for the diagnosis of Lisfranc injuries: 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. Further advanced imaging by CT or MRI may be required in patients with normal radiographs but with continued suspicion for Lisfranc injuries.

Level of evidence

4, systematic review.

Peer Review reports

Introduction

Lisfranc injury is a midfoot injury that refers to the displacement of one or more of the metatarsi from the tarsus [1]. The incidence is low, with approximately 0.2% of all fractures affecting one in every 55,000 people in the United States [2]. The wide-ranging characteristics of Lisfranc injury have been well documented, from low-energy ligamentous injuries commonly associated with sports activities to high-energy crushing injuries in traumatic events [1]. Systematic reviews have indicated that reasonable clinical outcomes can be expected in patients despite the wide-ranging characteristics of Lisfranc injury [3,4,5,6]. However, the diagnosis of Lisfranc injuries has remained a challenge, and is estimated to have been commonly missed or misdiagnosed in 20% to 24% of cases [7, 8]. Therefore, the current literature has recommended that clinicians obtain radiological imaging in patients with a highly suspicious history and/or physical findings of Lisfranc injuries [1].

A variety of radiological imaging modalities, that are radiographs, computed tomography (CT), and magnetic resonance imaging (MRI), can diagnose Lisfranc injuries [1, 9]. Among these varieties, radiographs remain the first line for demonstrating structural bony and soft tissue abnormalities, as image acquisition is non-invasive, inexpensive, and rapidly available [10]. However, the radiographic criteria for diagnosing Lisfranc injuries have been variable [11]. The establishment of standardised radiographic criteria for Lisfranc injuries can add foresight to the clinical decision-making of treatment choice and subsequently enhance patient consultation.

Therefore, the purpose of this study is to evaluate the radiographic diagnostic criteria and propose standardised radiographic criteria for Lisfranc injuries. The hypothesis is that the diagnostic criteria of Lisfranc injuries are heterogenous in the current literature.

Methods

Study design, search strategy and study identification

A systematic review of the PubMed and Embase databases was performed by two authors (D.S. and L.Y.T.C.) using specific search terms and eligibility criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines from inception to April 11, 2022 [12]. The purpose of this systematic review was to evaluate patients with Lisfranc injuries (P) diagnosed using radiological imaging and criteria (O) in clinical cohort studies, whereby P is the population, and O is the outcome based on the PICO framework of clinical research questions. The search terms were: (Lisfranc OR tarsometatarsal OR midfoot) AND (injury OR injuries OR fracture OR fractures OR dislocation OR dislocations OR displacement OR diastasis OR subluxation OR rupture OR ruptures OR sprain). The titles, abstracts and full texts were screened using specific eligibility criteria. The references of full-text studies for review were additionally screened for studies unidentified by the search strategy. Studies were included by the agreement of both authors and differences resolved by the senior author (Y.Y.).

Eligibility criteria

The inclusion criteria were: 1) clinical studies that used radiographic criteria for identification of Lisfranc injuries, 2) full-text studies and 3) written in English. The exclusion criteria were: 1) animal studies, 2) cadaver studies, 3) case reports, 4) in vitro studies and 5) reviews.

Assessment of evidence

The level of evidence (LoE) was assessed using the criteria by The Journal of Bone & Joint Surgery [13]. The above criteria use a hierarchical rating to evaluate the LoE from Level I through V based on the study design used to answer the primary research question. Level I studies has the highest QoE (randomised controlled trials), followed sequentially by Level II (prospective cohort), III (retrospective cohort), IV (case series), and V (non-clinical studies, case reports). The risk of bias (RoB) was assessed using the Risk of Bias in Non-Randomised Studies of Interventions (ROBINS-I) tool. The ROBINS-I tool rates studies as “Low”, “Moderate”, “Serious”, and “Critical” risk of bias based on the domains: bias due to confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and selection of the reported results [14]. The quality of evidence was evaluated using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach [15].

Data extraction and categorization

Data was extracted onto a Microsoft® Excel datasheet version 16 (Microsoft® Excel for Mac, Redmond, WA). The study/patient characteristics extracted were: Lisfranc injuries (n), sex, mean age and follow-up. The radiographic diagnostic characteristics extracted were: weightbearing condition(s) and if the contralateral radiograph was obtained. Radiographic criteria pertaining to the diagnosis of Lisfranc injuries were then extracted, with these consistencies evaluated across all the included studies.

Statistical analysis was performed using R version 3.5.1 (R Foundation for Statistical Computing, Vienna, Austria). Descriptive statistics were presented for all continuous and categorical variables. Continuous variables were presented as mean ± standard deviation and categorical variables as frequencies by percentages. A value of p < 0.05 was considered statistically significant.

Results

Literature search and study/patient characteristics (Table 1)

Table 1 Study/patient characteristics
Full size table

A literature search based on the search strategy revealed 4746 studies for review (Fig. 1). There were 3075 studies excluded in the initial screening as they did not include Lisfranc injuries in their population or were not clinical cohort studies. There were 29 studies that met the eligibility criteria and therefore, were included. The included studies were published between 1990 and 2022 [16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44]. The mean LoE was 3.41 ± 0.68 (range, 1 to 4) according to the criteria by The Journal of Bone and Joint Surgery. The RoB ranged from “Low” to “Moderate” risk according to the ROBINS-I tool (Fig. 2). The overall recommendations according to the GRADE assessment ranged from “Very Low” to “High” (Table 2). All Lisfranc injuries were confirmed by radiographs as per eligibility criteria. This totalled 1115 Lisfranc injuries. This translated to 600 males, 470 females and 45 unreported genders. The mean age was 34.82 ± 8.63 (range, 19.40 to 49). The mean follow-up was 35.18 ± 15.02 (range, 12.30 to 58.40) months.

Fig. 1
figure 1

PRISMA flow diagram

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Fig. 2
figure 2

Breakdown of QoE assessment by the ROBINS-I Tool

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Table 2 GRADE assessment
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Characteristics (Fig. 3)

Fig. 3
figure 3

Frequency of radiographic diagnostic criteria for Lisfranc injuries

Full size image

Weight-bearing radiographs were obtained in 12 studies [16, 19, 20, 25, 26, 28, 34,35,36, 39, 40, 44]. Two studies reported the use of (1) weight-bearing or non-weight-bearing radiographs [18, 43], and (2) weight-bearing and stress radiographs [33, 37]. One study used weight-bearing, non-weight-bearing, and stress radiographs [24]. The remaining 11 studies did not report the condition of their obtained radiographs [17, 21,22,23, 27, 30,31,32, 38, 41, 42]. Contralateral radiographs were fully obtained in 12 studies [16, 20, 24, 25, 28, 29, 35,36,37, 39, 40, 44]. One study was reported to have only obtained contralateral radiographs in four of nine of their patients [18], while another study obtained contralateral radiographs in three of eleven of their patients [19]. The remaining 15 studies did not report if contralateral radiographs were obtained for comparison [17, 21,22,23, 26, 27, 30,31,32,33,34, 38, 41,42,43]. The radiographic criteria reported in the 15 studies included (Table 3). In the anteroposterior view, the fleck sign, notch sign, medial column malalignment (C1-M1), C1-M2 diastasis, and M1-M2 diastasis. In the oblique view, C3-M3 subluxation, and cuboid-M4 subluxation. In the anteroposterior or oblique view, C1-C2 diastasis and C2-M2 subluxation. In the lateral view, cuneiform-metatarsal malalignment, longitudinal arch height, and talo-metatarsal angle.

Table 3 Radiographic diagnostic criteria for Lisfranc injuries
Full size table

Anteroposterior view

M1-M2 diastasis was the most common radiographic diagnostic criteria in the anteroposterior view, as was employed in 18 studies [16,17,18,19,20,21, 23, 25, 26, 28, 30, 33,34,35, 38, 40, 43, 44]. Specific distances for M1-M2 distance were reported in eight studies and employed at > 1 mm [22], > 2 mm [19, 35, 38, 40], > 3 mm [26, 33], or 2-5 mm [16]. 1st cuneiform to 2nd metatarsal diastasis was the second most common diagnostic criteria in the anteroposterior view and was employed in eight studies [29, 32, 36, 37, 40, 41, 43, 44]. Medial column alignment was reported in six studies [19, 29, 32, 40,41,42]. The fleck sign was fully employed in three studies [17, 20, 22] but mixed in three more other studies [23, 28, 34], and the notch sign was employed in one study [24].

Oblique view

3rd cuneiform to 3rd metatarsal [19, 21, 27, 31, 42,43,44] and cuboid to 4th metatarsal subluxation [19, 21, 23, 31, 42,43,44] were both the radiographic diagnostic criteria observed in the oblique view and employed in seven studies each.

Anteroposterior or oblique view

1st cuneiform to 2nd cuneiform diastasis and 2nd cuneiform to 2nd metatarsal subluxation were both the radiographic diagnostic criteria observed in the anteroposterior or oblique view. 2nd cuneiform to 2nd metatarsal subluxation was employed in 11 studies [19,20,21, 27, 29, 31, 32, 40, 42,43,44], whereas 1st cuneiform to 2nd cuneiform diastasis was employed in five studies [20, 23, 29, 32, 43].

Lateral view

The talometatarsal angle [21, 24, 27, 39, 40, 43, 44] and longitudinal arch height [19, 20, 24, 36, 39, 43, 44] were the most common radiographic diagnostic criteria in the lateral view, as employed in seven studies each. Cuneiform-metatarsal malalignment was employed in six studies [19, 21, 24, 31, 41, 42].

Discussion

The heterogeneous diagnostic criteria of many disorders remain prominent across medicine [11, 45,46,47], and the radiographic diagnostic criteria of Lisfranc injuries are no exception [11]. Radiographs are a key first-line diagnostic tool for Lisfranc injuries [48]. However, in patients with normal radiographs but with continued suspicion of Lisfranc injuries, further advanced imaging by CT or MRI is suggested [49]. This systematic review reinforced that the radiographic diagnostic criteria for Lisfranc injuries have been heterogeneous. There are currently no clear guidelines or consensus on the use of radiographic criteria for the diagnosis of Lisfranc injuries. This becomes problematic because varying pathological characteristics can be indicative of varying severities that may then be associated with poorer prognosis. Potential reasons for heterogeneity may stem from the complex anatomy surrounding Lisfranc injuries. From the included studies, it can be observed that diastasis between several bony landmarks can be used in identifying Lisfranc injuries. While this review concluded that the most commonly observed diastasis is at M1-M2 and C1-C2, there are no studies correlating radiological findings and clinical presentation of Lisfranc injuries (i.e. patient symptoms, functional scores). Hence, it is difficult to ascertain which diastasis may bear the most clinical significance. In addition, differences in institutional practices and protocols for diagnosing Lisfranc injuries may also contribute to heterogeneity of current diagnostic criteria. It is important to consider these potential reasons for heterogeneity when discussing and standardising radiographic diagnostic criteria for Lisfranc injuries to improve consistency of diagnoses. In a retrospective case series of 51 patients that examined pre-surgical non-weight-bearing radiographs to intra-surgical stability, it was revealed that 1st cuneiform to 2nd metatarsal avulsion (fleck sign on radiographs) and 1st cuneiform to 2nd cuneiform diastasis were strong pre-surgical radiographic predictors of instability [29]. Therefore, the generalised outcomes following Lisfranc injuries must be currently interpreted with caution, with homogenous radiographic diagnostic criteria urged to be established.

The fleck sign is another radiographic sign that has been recognised to be an indicator of primarily ligamentous injuries in some studies [22, 23] but not all studies [17, 20, 28, 34]. There appeared to be similar outcomes across the included studies with the fleck sign compared to those without the fleck sign on radiographs for Lisfranc injuries. Many surgeons have agreed that purely ligamentous injuries may require a longer healing time than their bony counterparts [26]. However, this was not observed for Lisfranc injuries based on the fleck sign recorded on radiographs in the current systematic review. A plausible reason may be due to the heterogeneous radiographic diagnostic criteria observed, and its subsequent potential to yield a possible ambiguous outcome. This may have also been confounded by only three studies having reported clinical outcomes with the Fleck sign [17, 20, 22].

Further to the inconsistent radiographic diagnostic criteria observed, there were studies excluded during the literature search because these studies reported radiographic indications for surgery rather than diagnostic criteria [50,51,52]. The decision to exclude these studies was based on the fact that indication for surgery is inherently different from diagnosis criteria. This circumstance calls into question the difference, if any, between the radiographic diagnostic criteria and radiographic indication for surgery for Lisfranc injuries. This scenario importantly emphasises the inconsistency present for not just radiographic diagnostic criteria but also the possibility of the radiographic indication for surgery and even the radiographic alignment criteria following the treatment for Lisfranc injuries. These inconsistencies further question the consensual understanding of Lisfranc injuries as a whole in the current literature. The establishment of a consensus must be rapidly made for the best clinical practice.

Based on the radiographic diagnostic criteria findings of this systematic review, the following proposed homogenous radiographic diagnostic criteria for Lisfranc injuries is 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. As observed in this systematic review, there have been varying degrees of 1st metatarsal to 2nd metatarsal diastasis that conferred a Lisfranc injury diagnosis. Still, it remains difficult to ascertain the cut-off point (the minimum value observed per this systematic review was 1 mm). Further studies are warranted to ascertain this, but what can be safely noted is that the 1st metatarsal to 2nd metatarsal diastasis of ≥ 2 mm was by far the most common radiographic diagnostic criteria. The next most common radiographic criterion was 2nd cuneiform to 2nd metatarsal subluxation, although no cut-off values were reported among the included studies. Theoretically, these radiographic criteria are sound indicators of the separation of the metatarsi from the tarsus as per the characteristics of a Lisfranc injury [1]. Further radiographic views such as oblique radiographs may support diagnosis of Lisfranc injuries if 1st metatarsal to 2nd metatarsal diastasis or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior views are equivocal. It is also proposed that the presence of a fleck sign is not to be necessarily included as a radiographic diagnostic criterion. Despite the fleck sign being recognised as a representation of primarily ligamentous injuries in some studies, there appeared to be no apparent association between the fleck sign on radiographs and the clinical outcomes of Lisfranc injuries. However, this may be confounded by fewer studies having reported clinical outcomes with than without the Fleck sign (three versus 26 studies, respectively). These propositions would ideally be in bilateral weight-bearing radiographs, although it is foreseeable that this might not always be possible in the acute setting. It is also ideal to have metatarsi alignment to their respective tarsi. Still, it is proposed that this is not to be made necessary and hence have not been included as part of the radiographic diagnostic criteria for Lisfranc injuries. Previous studies have demonstrated that radiographic measurements of tarsometatarsal alignment have limited ability to detect Lisfranc injuries because of the innate nature of tarsometatarsal anatomy that there is a normal step-off of the metatarsi edge compared to their respective tarsi [9, 11].

The current literature has also debated the superiority of radiographs compared to CT and MRI [9, 48, 53]. Radiographs are non-invasive, inexpensive, and rapidly available and therefore, are theoretically sound to be conferred as first-line. Some benefits of image acquisition by CT include greater detailed imaging for operative planning. CT has also been demonstrated to be best at detecting small bony displacements that may be otherwise missed in non-weight-bearing radiographs [54]. However, CT scans are more expensive compared to plain radiographs and any advantages that CT images provide must ultimately justify the increased cost. Kennelly et al. did suggest that these benefits are limited and may not impact management of Lisfranc injuries. In fact, only 12% of CT scans subsequently detected Lisfranc injuries after initial weight bearing radiographs were negative [48]. MRI imaging is known to be an excellent tool to assess soft tissue structures including the Lisfranc ligament, which is the interosseous ligament between the 1st cuneiform and 2nd metatarsal [55]. Kitsukawa et al. suggested that due to the oblique course of the Lisfranc ligament with respect to the anatomical body axis, 3-dimensional MRI is advantageous to assess Lisfranc injuries. In their study, the authors concluded that MRI identified Lisfranc ligament (interosseous C1-C2 ligament) injuries corresponded with intraoperative findings in all included patients [55]. This suggests that MRI provides excellent diagnostic accuracy for Lisfranc injuries. However, MRI does not appear suitable for first-line diagnosis due to its inherent nature to require a noteworthy amount of time for image acquisition and reduced ease of access compared to plain radiographs. In addition, using MRI as a first-line imaging modality may pose the risk of overdiagnosis in lower grade injuries as suggested by Macmohan et al. [56]. Therefore, this reiterates the importance of concrete radiographic diagnostic criteria to be rapidly achieved. Radiographic criteria between conventional radiographs and CT share some familiar imagery and therefore, can somewhat be cross-shared to have common diagnostic criteria between the two platforms. Noticeably, the fleck sign is visible on both radiographs and CT. In patients with normal radiographs but with continued suspicion of Lisfranc injuries, further advanced imaging by CT or MRI is suggested [49].

The strength of this study was that a comprehensive search strategy was employed to encompass all varying severities of Lisfranc injuries. However, there were several limitations to this study. These limitations can be divided into limitations of the systematic review and the limitations of the included studies. The limitations of the systematic review were that the eligibility was only limited to full-text studies written in English, which may have predisposed selection bias. Reviews have also been noted to summarise and aggregate data and may have comprised intrinsic bias [57]. In addition, the level of heterogeneity was not objectively quantified as the data obtained from included studies was inherently unsuited for meta-analysis. The limitations of the included studies were that inter-operator variability of the obtained radiographs for diagnosis in the included studies was inherently present. Factors beyond operator control may have also influenced the radiographs in the clinical setting. This may have included but was not limited to foot position, muscular tone, muscular relaxation, patient orientation and patient posture. The included studies did not report rates of missed diagnosis pertaining to each radiographic criterion. Hence the diagnostic accuracy of each radiographic sign could not be objectively evaluated, which limits clinical decision-making regarding which criteria to use in diagnosing Lisfranc injuries. The location of Lisfranc injuries (medial or lateral column) was not reported in the included studies. This limits the objective evaluation of the diagnostic accuracy of the proposed radiographic diagnostic criteria with respect to different classifications of Lisfranc injuries.

In conclusion, the radiographic diagnostic criteria of Lisfranc injuries were heterogeneous. The proposition for homogenous radiographic diagnostic criteria is that the following features must be observed for the diagnosis of Lisfranc injuries: 1st metatarsal to 2nd metatarsal diastasis on anteroposterior view or 2nd cuneiform to 2nd metatarsal subluxation on anteroposterior or oblique views. Further advanced imaging by CT or MRI may be required in patients with normal radiographs but with continued suspicion for Lisfranc injuries. Future studies are warranted to investigate the proposed radiographic diagnostic criteria and their association with clinical outcomes for Lisfranc injuries. Notably, if any radiographic diagnostic criteria can indicate severity or associated with poorer prognosis.

Availability of data and materials

Available on request to email Dr Dexter Seow at dexterseow@rcsi.ie.

References

  1. Moracia-Ochagavía I, Rodríguez-Merchán EC. Lisfranc fracture-dislocations: current management. EFORT Open Rev. 2019;4(7):430–44.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Cassebaum WH. Lisfranc fracture-dislocations. Clin Orthop Relat Res. 1963;30:116–29.

    Article  CAS  PubMed  Google Scholar 

  3. Magill HH, Bakr A, Hajibandeh S, Shaath M, Mehta J. Open reduction and internal fixation versus primary arthrodesis for the treatment of acute lisfranc injuries: a systematic review and meta-analysis. J Foot Ankle Surg. 2019;58(2):328–32.

    Article  PubMed  Google Scholar 

  4. Robertson GA, Ang KK, Maffulli N, Keenan G, Wood AM. Return to sport following lisfranc injuries: a systematic review and meta-analysis. Foot Ankle Surg. 2019;25(5):654–64.

    Article  PubMed  Google Scholar 

  5. Stavrakakis IM, Magarakis GE, Christoforakis Z. Percutaneous fixation of Lisfranc joint injuries: a systematic review of the literature. Acta Orthop Traumatol Turc. 2019;53(6):457–62.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Attia AK, Mahmoud K, Alhammoud A, d'Hooghe P, Farber D. Return to play after low-energy lisfranc injuries in high-demand individuals: a systematic review and meta-analysis of athletes and active military personnel. Orthop J Sports Med. 2021;9(3):2325967120988158. https://doi.org/10.1177/2325967120988158.

  7. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. 2004;183(3):615–22.

    Article  PubMed  Google Scholar 

  8. Naguib S, Meyr AJ. Reliability, surgeon preferences, and eye-tracking assessment of the stress examination of the tarsometatarsal (lisfranc) joint complex. J Foot Ankle Surg. 2019;58(1):93–6.

    Article  PubMed  Google Scholar 

  9. Preidler KW, Peicha G, Lajtai G, Seibert FJ, Fock C, Szolar DM, Raith H. Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. AJR Am J Roentgenol. 1999;173(6):1673–7.

    Article  CAS  PubMed  Google Scholar 

  10. Ponkilainen VT, Partio N, Salonen EE, Riuttanen A, Luoma EL, Kask G, Laine HJ, Mäenpää H, Päiväniemi O, Mattila VM, Haapasalo HH. Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in lisfranc injuries. Arch Orthop Trauma Surg. 2020;140(10):1423–9.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Sripanich Y, Weinberg MW, Krähenbühl N, Rungprai C, Mills MK, Saltzman CL, Barg A. Imaging in lisfranc injury: a systematic literature review. Skeletal Radiol. 2020;49(1):31–53.

    Article  PubMed  Google Scholar 

  12. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JP, Clarke M, Devereaux PJ, Kleijnen J, Moher D. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Ann Intern Med. 2009;151(4):W65–94.

    Article  PubMed  Google Scholar 

  13. Marx RG, Wilson SM, Swiontkowski MF. Updating the assignment of levels of evidence. J Bone Joint Surg Am. 2015;97(1):1–2.

    Article  PubMed  Google Scholar 

  14. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, Henry D, Altman DG, Ansari MT, Boutron I, Carpenter JR, Chan AW, Churchill R, Deeks JJ, Hróbjartsson A, Kirkham J, Jüni P, Loke YK, Pigott TD, Ramsay CR, Regidor D, Rothstein HR, Sandhu L, Santaguida PL, Schünemann HJ, Shea B, Shrier I, Tugwell P, Turner L, Valentine JC, Waddington H, Waters E, Wells GA, Whiting PF, Higgins JP. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Guyatt GH, Oxman AD, Schünemann HJ, Tugwell P, Knottnerus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol. 2011;64(4):380–2.

    Article  PubMed  Google Scholar 

  16. Faciszewski T, Burks RT, Manaster BJ. Subtle injuries of the lisfranc joint. J Bone Joint Surg Am. 1990;72(10):1519–22.

    Article  CAS  PubMed  Google Scholar 

  17. Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the athlete. Am J Sports Med. 1993;21(4):497–502.

    Article  CAS  PubMed  Google Scholar 

  18. Shapiro MS, Wascher DC, Finerman GA. Rupture of Lisfranc’s ligament in athletes. Am J Sports Med. 1994;22(5):687–91.

    Article  CAS  PubMed  Google Scholar 

  19. Kinik H, Erdemli B, Gürkan I, Arikan M, Mergen E. Surgical management of lisfranc injuries. Foot Ankle Surg. 1999;5(2):105–8.

    Article  Google Scholar 

  20. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871–8.

    Article  PubMed  Google Scholar 

  21. Perugia D, Basile A, Battaglia A, Stopponi M, De Simeonibus AM. Fracture dislocations of Lisfranc’s joint treated with closed reduction and percutaneous fixation. Int Orthop. 2003;27(1):30–5.

    Article  PubMed  Google Scholar 

  22. Ly TV, Coetzee JC. Treatment of primarily ligamentous lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation: a prospective, randomized study. J Bone Joint Surg Am. 2006;88(3):514–20.

    PubMed  Google Scholar 

  23. Reinhardt KR, Oh LS, Schottel P, Roberts MM, Levine D. Treatment of lisfranc fracture-dislocations with primary partial arthrodesis. Foot Ankle Int. 2012;33(1):50–6.

    Article  PubMed  Google Scholar 

  24. Crates JM, Barber FA, Sanders EJ. Subtle lisfranc subluxation: results of operative and nonoperative treatment. J Foot Ankle Surg. 2015;54(3):350–5.

    Article  PubMed  Google Scholar 

  25. 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;135(8):1063–70.

    Article  PubMed  Google Scholar 

  26. Cassinelli SJ, Moss LK, Lee DC, Phillips J, Harris TG. Delayed open reduction internal fixation of missed, low-energy lisfranc injuries. Foot Ankle Int. 2016;37(10):1084–90.

    Article  PubMed  Google Scholar 

  27. Del Vecchio JJ, Ghioldi M, Raimondi N, De Elias M. Minimally invasive medial plating of low-energy lisfranc injuries: preliminary experience with five cases. Adv Orthop. 2016;2016:4861260.

    PubMed  PubMed Central  Google Scholar 

  28. Lien SB, Shen HC, Lin LC. Combined innovative portal arthroscopy and fluoroscopy-assisted reduction and fixation in subtle injury of the lisfranc joint complex: analysis of 10 cases. J Foot Ankle Surg. 2017;56(1):142–7.

    Article  PubMed  Google Scholar 

  29. Seo DK, Lee HS, Lee KW, Lee SK, Kim SB. Nonweightbearing radiographs in patients with a subtle lisfranc Injury. Foot Ankle Int. 2017;38(10):1120–5.

    Article  PubMed  Google Scholar 

  30. Gee S, Harris MC, Anderson C, Groth A, Ryan P. Lisfranc open reduction and internal fixation in an athletic population: screw versus suture button fixation. Curr Orthop Pract. 2019;30(4):323–6.

    Article  Google Scholar 

  31. Pigott MT, Shah R, Chan J, Irwin TA, Holmes JR, Talusan PG. Initial displacement does not affect loss of reduction after lisfranc fracture dislocations. Foot Ankle Spec. 2019;12(6):535–9.

    Article  PubMed  Google Scholar 

  32. Porter DA, Barnes AF, Rund A, Walrod MT. Injury pattern in ligamentous lisfranc injuries in competitive athletes. Foot Ankle Int. 2019;40(2):185–94.

    Article  PubMed  Google Scholar 

  33. Ren W, Li HB, Lu JK, Hu YC. Undisplaced subtle ligamentous lisfranc injuries, Conservative or surgical treatment with percutaneous position screws? Chin J Traumatol. 2019;22(4):196–201.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Chen P, Ng N, Snowden G, Mackenzie SP, Nicholson JA, Amin AK. Rates of displacement and patient-reported outcomes following Conservative treatment of minimally displaced Lisfranc Injury. Foot Ankle Int. 2020;41(4):387–91.

    Article  PubMed  Google Scholar 

  35. Cho J, Kim J, Min TH, Chun DI, Won SH, Park S, Yi Y. Suture button vs conventional screw fixation for isolated lisfranc ligament injuries. Foot Ankle Int. 2021;42(5):598–608.

    Article  PubMed  Google Scholar 

  36. Thomas JL, Kopiec A, Mark K, Chandler LM. Radiographic value of the Lisfranc diastasis in a standardized population. Foot Ankle Spec. 2020;13(6):494–501.

    Article  PubMed  Google Scholar 

  37. Arzac Ulla I. Persistent instability in pure ligamentous lisfranc joint injuries. Foot Ankle Surg. 2021;27(7):793–8.

    Article  PubMed  Google Scholar 

  38. Chen P, Ng N, Snowden G, Mackenzie SP, Nicholson JA, Amin AK. Percutaneous reduction and fixation of low energy lisfranc injuries results in better outcome compared to open reduction and internal fixation: results from a matched case-control study with minimum 12 months follow up. Injury. 2021;52(4):1042–7.

    Article  PubMed  Google Scholar 

  39. Eceviz E, Çevik HB, Öztürk O, Özen T, Çolak TK, Çolak İ, Polat MG. Pedobarographic, clinic, and radiologic evaluation after surgically treated lisfranc injury. J Invest Surg. 2021;34(11):1191–7.

    Article  PubMed  Google Scholar 

  40. Garríguez-Pérez D, Puerto-Vázquez M, Tomé Delgado JL, Galeote E, Marco F. Impact of the subtle Lisfranc Injury on Foot structure and function. Foot Ankle Int. 2021;42(10):1303–10.

    Article  PubMed  Google Scholar 

  41. Mosca M, Fuiano M, Censoni D, Marcheggiani Muccioli GM, Roberti di Sarsina T, Grassi A, Caravelli S, Zaffagnini S. A mid-term follow-up retrospective evaluation of tarsometatarsal joint fracture-dislocations treated by closed reduction and percutaneous K-wires fixation. Injury. 2021;52(6):1635–40.

    Article  PubMed  Google Scholar 

  42. So E, Lee J, Pershing ML, Chu AK, Wilson M, Halaharvi C, Mandas V, Hyer CF. A comparison of Complications and reoperations between open reduction and internal fixation versus primary arthrodesis following lisfranc injury. Foot Ankle Spec. 2021;28:19386400211058264.

    Google Scholar 

  43. De Bruijn J, Hagemeijer NC, Rikken QGH, Husseini JS, Saengsin J, Kerkhoffs GMMJ, Waryasz G, Guss D, DiGiovanni CW. Lisfranc injury: Refined diagnostic methodology using weightbearing and non-weightbearing radiographs. Injury. 2022;S0020–1383(22):00145.

    Google Scholar 

  44. Rikken QGH, Hagemeijer NC, De Bruijn J, Kaiser P, Kerkhoffs GMMJ, DiGiovanni CW, Guss D. Novel values in the radiographic diagnosis of ligamentous lisfranc injuries. Injury. 2022;S0020–1383(22):00150–4.

    Google Scholar 

  45. James EW, Williams BT, LaPrade RF. Stress radiography for the diagnosis of knee ligament injuries: a systematic review. Clin Orthop Relat Res. 2014;472(9):2644–57.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Large TM, Agel J, Holtzman DJ, Benirschke SK, Krieg JC. Interobserver variability in the measurement of lower leg compartment pressures. J Orthop Trauma. 2015;29(7):316–21.

    Article  PubMed  Google Scholar 

  47. Sörelius K, Wanhainen A, Mani K. Infective native aortic aneurysms: call for consensus on definition, terminology, diagnostic criteria, and reporting standards. Eur J Vasc Endovasc Surg. 2020;59(3):333–4.

    Article  PubMed  Google Scholar 

  48. Kennelly H, Klaassen K, Heitman D, Youngberg R, Platt SR. Utility of weight-bearing radiographs compared to computed tomography scan for the diagnosis of subtle lisfranc injuries in the emergency setting. Emerg Med Australas. 2019;31(5):741–4.

    Article  PubMed  Google Scholar 

  49. Expert Panel on Musculoskeletal Imaging, Gorbachova T, Chang EY, Ha AS, Amini B, Dorfman SR, Fox MG, Khurana B, Klitzke A, Lee KS, Mooar PA, Shah KH, Shah NA, Singer AD, Smith SE, Taljanovic MS, Thomas JM, Kransdorf MJ. ACR appropriateness Criteria® Acute Trauma to the Foot. J Am Coll Radiol. 2020;17(5S):2–S11.

    Google Scholar 

  50. Fan MQ, Li XS, Jiang XJ, Shen JJ, Tong PJ, Huang JF. The surgical outcome of lisfranc injuries accompanied by multiple metatarsal fractures: a multicenter retrospective study. Injury. 2019;50(2):571–8.

    Article  PubMed  Google Scholar 

  51. Park YH, Ahn JH, Choi GW, Kim HJ. Percutaneous reduction and 2.7-mm cortical screw fixation for low-energy lisfranc injuries. J Foot Ankle Surg. 2020;pii:S1067–2516(20):30086–7.

    Google Scholar 

  52. Vopat BG, Vopat ML, van Dijk PAD, Hazzard S, McKinnon K, Asnis PD, Theodore GH. Return to sport after surgical treatment of lisfranc injuries in athletes: a retrospective case series. Kans J Med. 2019;12(4):141–5.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Goiney RC, Connell DG, Nichols DM. CT evaluation of tarsometatarsal fracture-dislocation injuries. AJR Am J Roentgenol. 1985;144(5):985–90.

    Article  CAS  PubMed  Google Scholar 

  54. Lu J, Ebraheim NA, Skie M, Porshinsky B, Yeasting RA. Radiographic and computed tomographic evaluation of lisfranc dislocation: a cadaver study. Foot Ankle Int. 1997;18(6):351–5. https://doi.org/10.1177/107110079701800608.

  55. Kitsukawa K, Hirano T, Niki H, Tachizawa N, Mimura H. The diagnostic accuracy of MRI to evaluate acute Lisfranc joint injuries: comparison with direct operative observations. Foot Ankle Orthop. 2022;7(1). https://doi.org/10.1177/24730114211069080.

  56. MacMahon PJ, Dheer S, Raikin SM. MRI of injuries to the first interosseous cuneometatarsal (lisfranc) ligament. Skeletal Radiol. 2009;38:255–60.

    Article  CAS  PubMed  Google Scholar 

  57. Haidich AB. Meta-analysis in medical research. Hippokratia. 2010;14(Suppl 1):29–37.

    CAS  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. National University Health System, Singapore, Singapore

    Dexter Seow

  2. Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore

    Dexter Seow & Li Yi Tammy Chan

  3. Department of Orthopaedic Surgery, School of Medicine, Teikyo University, 2-11-1, Kaga, Itabashi, Tokyo, 173-8605, Japan

    Youichi Yasui, Maya Kubo, Masashi Nei, Kentaro Matsui, Hirotaka Kawano & Wataru Miyamoto

  4. Royal College of Surgeons in Ireland, Dublin, Ireland

    Gareth Murray

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Investigation was performed at Department of Orthopaedic Surgery, School of Medicine, Teikyo University, Tokyo, Japan.

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Seow, D., Yasui, Y., Chan, L. et al. Inconsistent radiographic diagnostic criteria for lisfranc injuries: a systematic review. BMC Musculoskelet Disord 24, 915 (2023). https://doi.org/10.1186/s12891-023-07043-z

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BMC Musculoskeletal Disorders

ISSN: 1471-2474

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