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Scientific Articles:
Steven M. Raikin, Ilan Elias, Sachin Dheer, Marcus P. Besser, William B. Morrison, and Adam C. Zoga
Prediction of Midfoot Instability in the Subtle Lisfranc Injury. Comparison of Magnetic Resonance Imaging with Intraoperative Findings
J Bone Joint Surg Am 2009; 91: 892-899 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Dr. Raikin and colleagues respond to Dr. Summerhays and colleagues
Steven M. Raikin, MD, Adam C. Zoga, MD; William B. Morrison, MD   (28 May 2009)
[Read Letter to the Editor] Prediction of Midfoot Instability in Subtle Lisfranc Injury
Ben J. Summerhays, DPM, J. George Devries, DPM; Michael J. Nute, DPM; Mario N. Ponticello, DPM; Brandon Scharer, DPM   (28 May 2009)

Dr. Raikin and colleagues respond to Dr. Summerhays and colleagues 28 May 2009
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Steven M. Raikin, MD,
Orthopaedic Surgeon
Thomas Jefferson University Hospital, Philadelphia, PA,
Adam C. Zoga, MD; William B. Morrison, MD

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Re: Dr. Raikin and colleagues respond to Dr. Summerhays and colleagues

steven.raikin{at}rothmaninstitute.com Steven M. Raikin, MD, et al.

We thank Dr. Summerhays and colleagues for their letter regarding our study on “Prediction of Midfoot Instability in Subtle Lisfranc Injury” (1).

With regard to the bundles, we did not find isolated ligamentous bands between the medial cuneiform and the second metatarsal base. Instead, we consistently observed two intimate but distinct ligamentous bundles running between the planatar central cuneiform and the second/third metatarsal bases. These bundles are morphologically analagous to the two bundles of an anterior cruciate ligament (ACL) and may very well be contained within one synovial sheath. With recently improved MRI technology and gradient strength, we routinely observe both of these bundles on all high-quality examinations. In this study, we grouped the two bundles together (which may represent the “Lisfranc” and pC1-M2M3 ligaments) describing a rupture as incompetence of both bundles, which may in fact occur as a single entity (as with the ACL) during the injury mechanism.

With regard to the question about the existence of the pC2-M2 ligament, Sarrafian does describe a variant of a ligament band running between the plantar lateral aspect of the second metatarsal and the middle cuneiform. Additionally MRI evaluation of uninjured feet demonstrate a clear capsular band plantarly in this region, akin to a plantar plate like structure. Whether one calls it a thickened joint capsule or a ligament may be a matter of semantics, but the connective tissue at the plantar aspect of the cuneiform-metatarsal articulations was clearly injured in many of our patients, based upon the review of two experienced musculoskeletal radiologists, and was not a reproducible sign of midfoot instability.

Reference

1. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91:892-9.
Prediction of Midfoot Instability in Subtle Lisfranc Injury 28 May 2009
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Ben J. Summerhays, DPM
Wheaton Franciscan Healthcare-St. Joseph's Milwaukee, WI,
J. George Devries, DPM; Michael J. Nute, DPM; Mario N. Ponticello, DPM; Brandon Scharer, DPM

Send letter to journal:
Re: Prediction of Midfoot Instability in Subtle Lisfranc Injury

bensummerhays44{at}hotmail.com Ben J. Summerhays, DPM, et al.

To the Editor:

In their recent article (1), Raiken et al. conclude that MRI is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when there is rupture of the plantar ligament bundle between the medial cuneiform and bases of metatarsals 2 and 3 (pC1-M2M3). The authors also looked to see if injury to other ligamentous structures of the Lisfranc joint could be used to determine instability. We have a few observations regarding this study.

Sarrafian (2) states that the Lisfranc ligament is the first interosseous cuneo1-metatarsal2 ligament arising from the lateral surface of the first cuneiform in front of the intercuneiform ligament, and under the particular surface corresponding to the second metatarsal. The ligament is directed obliquely outward and slightly downward and inserts on the lower half of the medial surface of the second metatarsal base. Sarrafian also states that the ligament is distinct from the dorsal and plantar ligaments (2). In their article (1), Raikin et al. do not make reference to this interosseous ligament.

Kaar et al. (3) found that both the pC1-M2M3 ligament and Lisfranc ligament must be ruptured for transverse instability to occur. Perhaps evaluating the MR images for possible rupture or tear of the interosseous Lisfranc ligament would provide better correlation with Lisfranc joint complex stability. Preidler et al. (4) in their study on the tarsometatarsal joint MR imaging pointed out the effectiveness and ability to view the Lisfranc ligament in all planes of MR imaging.

Raikin et al. (1) state several times that rupture of the plantar cuneiform 2-metatarsal 2 ligament was identified in the majority (18) of the 21 feet, but this was not useful in predicting stability. However, Sarrafian (2), Kaar et al. (3) , and Kura et al. (5) all have found that there is no plantar ligament between the second cuneiform and second metatarsal; thus its absence, or apparent rupture is likely normal anatomy.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References

1. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc Injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91:892-9.

2. Sarrafian SK. Anatomy of the foot and ankle: descriptive, topographic, functional. 2nd ed. Philadelphia: Lippincott Williams and Wilkins; 1993. p 205-6.

3. Kaar S, Femino J, Morag Y. Lisfranc joint displacement following sequential ligament sectioning. J Bone Joint Surg Am. 2007;89:2225-32.

4. Preidler KW, Wang YC, Brossmann J, Trudell D, Daenen B, Resnick D. Tarsometatarsal joint: anatomic details on MR images. Radiology. 1996;199:733-6.

5. Kura H, Luo ZP, Kitaoka HB, Smutz WP, An KN. Mechanical behavior of the Lisfranc and dorsal cuneometatarsal ligaments: in vitro biomechanical study. J Orthop Trauma. 2001;15:107-10.