Neoligamentplasty for the Treatment of Subtle Ligament Lesions of the Intercuneiform and Tarsometatarsal Joints Caio Nery, MD,* Cibele Re ´ssio, MD,w and Jose ´ Felipe Marion Alloza, MDw z Abstract: Between 1995 and 2007, 20 patients with subtle Lisfranc joint injuries were treated. All patients confirmed that they had suffered a foot sprain with the forefoot fixed to the surface. In 12 patients (60%), the accessory force acted in eversion and in 8 patients (40%), in inversion. Only 11 patients (55%) showed radiographic signs that could confirm the suspicion of the clinical diagnosis. Magnetic resonance images confirmed the involvement of anatomic structures in all of them. The ruptured ligaments were explored and their residue removed---one of the aims of the surgery that will control the pain and lead to the reduction of the joints. After the reduction, drill holes were made to reproduce the isometrics and anatomy of the torn ligaments. After an average follow-up of 8 years (2-13 y), 17 patients (85%) were considered as having excellent or good results (complete recovery of motion and power; no pain; no soft tissue or bone reaction to the neoligaments; no loss of anatomic reduction); and 3 patients (15%) had fair or poor results (arthritis). Resection of torn ligaments, anatomic reduction of the subluxated joints, and isometric reconstruction of the ligaments showed to be an excellent solution to the subtle Lisfranc injuries and an alternative to other methods of treatment. Key Words: Lisfranc injury, Lisfranc ligament, treatment, Lisfranc complex, ligament reconstruction (Tech Foot & Ankle 2010;9: 92--99) HISTORICAL PERSPECTIVE Compared with the other foot and ankle injuries, fracture dislocations of the intercuneiform and tarsometatarsal joint are not commom. 1–19 The incidence of this type of trauma is 1:60,000 patients per year. They are worrisome injuries because as many as 20% are misdiagnosed or overlooked. 10 When the intertarsal and tarsometatarsal ligament lesions are brought into focus, the percentage of unrecognized cases may be much bigger than that. The incidence of the pure ligament lesion is unknown, the diagnosis is very difficult to make, and there is no consensus about the treatment. The description of injuries caused by direct or indirect forces is found in the literature. The most serious are high- energy traumas with great amounts of soft tissue disruption, fractures, and subluxation of the joints. However, this is beyond the scope of our study. In this study, we will focus on the kind of injury caused by a low-energy, indirect force combined with rotational movements. The typical example is ‘‘foot sprain’’ when running or playing on a yielding surface or a twist of the forefoot while stepping in a hole on the ground or by falling from a wind-surf board while the foot remains fixed by the foot-strap. 20 The classification system proposed by Nunley and Vertullo 21 addresses the subtle, soft tissue injuries that affect the ligament structures with or without small fleck or avulsed fractures. According to the investigators, stage I includes sprain of the tarsometatarsal ligaments with no diastasis between the bones or loss of medial arch height on weight- bearing radiographs—the Lisfranc complex is stable; in stage II there is a diastasis up to 5 mm between the medial cuneiform and the base of the second metatarsal but there is no loss of the medial arch height—the Lisfranc ligament may be torn but there are still ligaments enough to keep the complex in the correct place; stage III sprains result in diastasis greater than 5 mm and reduction of the medial arch height—both the Lisfranc and the ‘‘Y’’ plantar ligaments are injured. We agree with these investigators and understand the concept of ‘‘subtle’’ as the conjunction of ligamentar, bone, and capsular lesions resulting from a low-energy traumatic agent that can cause different grades of painful functional instability of the midtarsal and tarsometatarsal region. The treatment options found in the literature are closed reduction with a nonweight bearing cast, 2,12,17 closed reduction with percutaneous K-wire fixation, 4,6,7,9,11,17,22 closed or open reduction with internal fixation (screws), 2,3,8,10 external fixation, 23 bridge plates with or without ligament repair, 24 suture-button fixation, and arthrodesis. 22,23,25,26 Although good results have been achieved with these treatment options in the literature, sometimes it seems to be excessive, especially in cases with subtle lesions. We believe that, even in joints with restricted movements as those in the tarsal and tarsometatarsal regions, it is advisable to keep its functional mobility and stability so that the anatomic reconstruction of the regional ligaments could bring better results than the percutaneous fixation, internal fixation with pins or screws or arthrodesis. 27,28 The aim of this study was to introduce a new method of treatment—the open reduction and neoligamentplasty of the tarsal and tarsometatarsal ligaments—and show the midterm results obtained in a small number of patients. PREOPERATIVE PLANNING Anatomy and Physiopathology It is very important to remember the local anatomy 29,30 and the most frequent trauma mechanisms 7,31 because the rationale of the surgical treatment is based on this knowledge. The ligaments connecting the cuneiforms and the cuboid to the metatarsal bases are distributed in 3 layers: dorsal, interosseous, and plantar ligaments. Copyright r 2010 by Lippincott Williams & Wilkins From the *Orthopaedic Discipline; wFoot and Ankle Clinic; and zSports Medicine Clinic, Federal University of Sa ˜o Paulo---UNIFESP, Escola Paulista de Medicina, Sa ˜o Paulo, Brazil. The authors have nothing to disclose related to the subject of this paper. Address correspondence and reprint requests to Caio Nery, MD, Av. Rouxinol 404--2nd floor, 04516-000, Sa ˜o Paulo--SP, Brazil. E-mail: caionerymd@gmail.com. SPECIAL FOCUS 92 | www.techfootankle.com Techniques in Foot & Ankle Surgery  Volume 9, Number 3, September 2010