MaCalus V. Hogan, MD, Orthopedic Foot and Ankle Specialist, Director Chief of Foot and Ankle Division, Lead of Sports Foot and Ankle Injury Program, Vice Chairman of Education and Residency Program Director at the University of Pittsburgh Medical Center talks about Lisfranc injuries.
Interview conducted by Ivanhoe Broadcast News in January 2018.
Do you specialize in sports injury?
Dr. Hogan: It’s a significant component of my practice, I would say sports injuries around the foot and ankle probably encompasses about forty or fifty percent of my overall practice.
Tell me about a Lisfranc injury, I had never heard of it before. What is it?
Dr. Hogan: A Lisfranc injury presents instability of the mid-foot. It was described by a gentleman whose name was Lisfranc during the Napoleonic era in which horse riders, if they fell off their horse, would have a rotational injury of their foot while their foot was still in the stirrup on the horse and so that was where it was originally described. Years ago, several hundred years ago, one of the only treatments for such an injury to the foot included amputation or there was considerable disability and an inability to use that foot going forward. The ligament, the Lisfranc ligament, is one of the main stabilizers of the mid-foot and the arch so the components of that are injured when someone has a Lisfranc injury.
It was then, if you’re talking about amputation, a very serious injury, these days still pretty serious?
Dr. Hogan: Definitely a significant injury, however a large majority do not require an amputation. We’ve advanced to a point where we have the ability to detect and manage them better. There are different grades of injury now; some may be subtle in which there is just injury to the ligament and that is a mild or low-grade injury, or it can progress all the way through very high-energy injuries that involve either complete injury to the ligaments of the Lisfranc complex or ligament injury in combination with fractures around the mid-foot.
Is this common in younger athletes? Tell me how often you see this injury and what age, what range?
Dr. Hogan: Yeah. There are types of Lisfranc injury some again are high energy; you may have a motor vehicle accident, significant falls from height and you may have a bony fracture with those. There are several approaches at managing those. In the athletic population we like to describe those as subtle Lisfranc injuries or in a lot of cases they can be purely ligamentous where there’s no actual bony fracture but there is a ligamentous injury that is pretty severe and significant. It is in those scenarios that we have to be very vigilant and be very thorough with our evaluation because you don’t see a fracture on X-ray. So everything really is from physical exam, understanding how the injury occurred, and that represents a large component of those injuries that happen in athletes.
Can it be misdiagnosed at first and if it is misdiagnosed, what is the concern or the risk to the athlete or person?
Dr. Hogan: Lisfranc injuries some consider them just mid-foot sprains. It’s a ligament around the mid-foot, you have a sprain. You step off a curb awkwardly or you land awkwardly, particularly in high-impact sports; a lot of rotational injury and stresses are going across the foot particularly in a soccer player or a football player. So if they are missed, that ligament is so important to your stability, it could be a problem for you long-term; particularly if it’s not treated appropriately. Most studies still quote that twenty to thirty percent of these injuries are missed when evaluated by maybe the not as experienced healthcare provider or in the setting or absence of a fracture or significant swelling. Sometimes the severity of what’s really taking place may not always be appreciated.
Are these career-ending injuries in most cases?
Dr. Hogan: They are potentially career ending and it depends on what people are doing. With sports there is a considerable amount of running, jumping, different movements like this. In a lot of high-impact sports the Lisfranc complex is essential for your ability to stabilize the foot for push off. If that is not managed well the instability can prevent someone from being able to return to that higher level of competitive play in sport. So there in lies career ending potential and we definitely watch these closely with that in mind.
In soccer or football how does this injury occur? Is it just moving the wrong way?
Dr. Hogan: Yeah, so it’s very interesting. It’s one of those injuries we know that there’s a certain loading that occurs across the foot while there’s also a rotational component to this. You really have a stress going across the foot at different vectors and in different directions. Sometimes it could be as simple as landing the wrong way and the foot twisting. In other scenarios the foot may be pivoted into the ground such as an altering force hit the individual. But we know there is a loading and rotational component that leads to this. A lot of research is actually going into how these develop, particularly in jumpers, in dancers, and in gymnastics. Anyone who is doing a lot of high-impact running and jumping there is a potential risk there.
You mentioned it’s both a ligament injury and it can be a fracture too?
Dr. Hogan: They’re different yes ma’am. They’re different types of injuries, you have some that are purely ligamentous where there is no bony injury but the Lisfranc ligaments have been injured. When those ligaments are injured it leads to too much motion across the mid-foot bones and when that instability is present you lose your ability to stabilize the foot as a lever to push off. In some cases you also have a fracture when the energy associated with the fracture with the injury, leads to a brake in one of the bones in the mid-foot.
Tricky to treat, and how do you go about treating it?
Dr. Hogan: There are different approaches and if the instability and malalignment of the foot is felt to be that it would not heal well on its own, they would usually take an approach for internal fixation. There are different approaches for managing that and you’re really trying to create stability for the ligaments to heal in the best position possible long-term. The approach that I usually take is what I describe as joint-sparing or intra-articular plating approach. This is when we use hardware in different positions to stabilize the joints while the ligaments heal. We also use either a solid screw or in some cases what we call a suture-type screw device, fixation device to stabilize the mid-foot and recreate the stability that would come with the ligaments being intact.
How long does it take usually for the ligament to heal, for the fracture to heal when you have that hardware?
Dr. Hogan: It usually takes at least a minimum of six weeks of biologic healing before we allow individuals to walk on this. Also in many cases we go back in and remove the hardware somewhere between four and five months in most cases. Though we allow rehab, joint motion, and strengthening to occur I do not allow them to return to high-impact activities until after the hardware has been removed; that’s usually at least four months, with hopeful return to competitive play after that time.
How tough is it to come back from something like that?
Dr. Hogan: It’s a difficult injury; it’s a challenge in most cases. When we’re speaking with athletes; if it occurs during a season we advice them that they will likely lose that particular season at minimum and that’s a pretty widely accepted understanding for specialists who treat these injuries across the country.
Any other approaches that are not surgical? Are there minimal approaches?
Dr. Hogan: Lisfranc injuries, particularly those that are unstable, the best treatment is surgery and surgical stabilization. If they have a low-grade injury, or a grade one, lower-grade injury, and there’s good alignment of the bones and significant instability is not present; in some of those cases you can treat a patient with protected or non-weight bearing in either a boot or a cast for a period of time until they’re stable. Then from there monitor their exam and their X-rays and imaging to see how they improve.
Can you talk to me a little bit about Lindsey’s case?
Dr. Hogan: Lindsey’s case was fun, in that sense I mean she and her family have always been fun to see and take care of even though we obviously met on less than ideal terms. Lindsey plays very competitive soccer for her school and also for her club team in the area and had a pretty high-impact rotational event that she described to me. She had one of our trainers here, Donna from our athletic training program who helps take care of her school, who immediately upon her having the injury said she really couldn’t walk on her foot. That is what also will happen, something that’s a sprain you may not be able to walk on it initially but you should be able to regain some level of weight bearing on it. So there was a very high level of suspicion that Donna had at the time and from the time I saw her and examined her I was very confident that she had a ligamentous Lisfranc injury. Which if not appreciated early on can lead to problems and delay in management. So we spoke with her family extensively during the first visit and set up a follow-up visit within a week of the first visit so they could really kind of absorb what were telling them and the discussions we were having. My recommendation for her was for surgical stabilization from the beginning from what I appreciated.
Was there ever a concern that she would not be able to go back to soccer?
Dr. Hogan: I talked to her family about it, I felt in her case she was young, athletic, very strong, that the chances of returning were higher than others. But I did speak with them about the fact that this is pretty severe and some people come back with so much pain or discomfort around the foot that it may be difficult for them to compete at the level that they had done previously. They understood that and we spoke about it each visit. But I was confident she has a lot of drive, she’s very motivated. I mean she was determined to get back and young and healthy so we gave her the best opportunity to succeed and she has done well.
Can you describe the hardware that you had in her foot to stabilize it?
Dr. Hogan: In her particular case I used a stainless steel plate, it was a locking plate. With her about six screws, it was a plate and about six screws to stabilize her foot. We placed those, and then took them out about four months later.
So four months with the plates in place. When you see her now what do you think, she’s out and moving?
Dr. Hogan: Yeah, she’s doing well, I mean she has essentially no restrictions so I told her to go out and have a good time and she’s doing great. I hear more about how well she’s doing than I even see her so that’s always a positive, I’m happy we were able to help her.
How frequent is this, do you have any percentage of how many are treated a year?
Dr. Hogan: With Lisfranc injuries over all, all ligamentous and those with fractures, it happens quite a bit. I mean the incidence I’m going to say one in fifty thousand some studies will quote. But with athletes if you’re including sprains, those that are stable and can be treated conservatively and those that are unstable, it’s one of those things we have a very high suspicion for. So with my practice having a pretty large component of sports foot and ankle injuries I see a fair amount of them. There’s pretty much not a month that goes by that I do not see at least one or two of these in some capacity in my current practice.
An abnormal twisting of the foot causes the ligament to tear?
Dr. Hogan: Yes there’s a loading of the foot, particularly when someone is on their toes that leads to a stress that pretty much travels up from the toes to the middle of the foot, more at the level of the arch. That combined with a component of rotation that often leads, and that’s what we feel pretty strongly, to these injuries. If you really look back at a lot of video analysis of athletes it always happens quickly and it’s very subtle. A lot of our efforts to try to recreate the injury in the lab and in the research setting have not been perfect because it’s such a complex injury. But yes it’s a load particularly when someone is in and elevated or on toe position with a rotational component that leads to this.
The ligament is on the—
Dr. Hogan: There are components of the ligament yes. So there’s a component of the ligament that’s plantar on the bottom of the foot and also a dorsal component. The plantar component is the stronger of those two components and there are others that contribute to that complex. But of the key Lisfranc ligaments there’s a dorsal component and a plantar component, the plantar being the strongest. And often those who have higher degree injuries the plantar ligaments are involved.
Is there anything I didn’t ask you that you would want people to know?
Dr. Hogan: These are difficult injuries, I’m fortunate to be in a place with a lot of good people with heightened awareness. We have a great group of people that help manage this and so these patients, well we’re fortunate if they get to us soon and early and we’re able to manage them with a better prediction of expectation and outcome. For those who may be curious or suspect that they may have an injury like this I just would advice them to seek out consultation with an orthopedic surgeon who specializes in this arena, particularly foot and ankle specialists or sport medicine specialists so that they can have the appropriate initial evaluation.
Missed diagnosed and years after the fact, not much you can do?
Dr. Hogan: If a delay in management of this actually occurs, then instability of the foot continues. Essentially every step, ever high-impact effort they try leads to more pressure across the joints and the cartilage along those joints. That can then lead to post-traumatic arthritis and often the only outcome in managing that would be a fusion arthrodesis which is a more definitive procedure and also it’s very difficult to return to high-impact play in a lead sports with that. Also the recovery is longer and the impact on one’s daily activity is greater; that is why you really want to get to these sooner than later.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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