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Injury, Int. J. Care Injured xxx (2017) xxxxxx

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Stability of Lisfranc injury xation in Thiel Cadavers: Is routine xation

of the 1st and 3rd tarsometatarsal joint necessary?
Alistair I.W. Mayne* , Robert Lawton, Stephen Dalgleish, Fraser Harrold, George Chami
Department of Trauma and Orthopaedic Surgery, Ninewells Hospital and Medical School, Dundee, DD1 9SY, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Background: There is debate as to whether a home run screw (medial cuneiform to 2nd metatarsal base)
Accepted 8 April 2017 combined with k-wire xation of the 4th & 5th tarsometatarsal joints is sufcient to stabilise Lisfranc
injuries or if xation of the 1st and 3rd tarsometatarsal joints is also required. Unlike the 2nd, 4th and 5th
Keywords: tarsometatarsal joints, stabilisation of the 1st and 3rd requires either intra-articular screw or an extra-
Lisfranc articular plate which risk causing chondrolysis and/or osteoarthritis.
Tarsometatarsal joint The aims of this cadaveric study were to determine if routine xation of the 1st and 3rd tarsometatarsal
Surgery
joints is necessary and to determine if a distal to proximal home run screw is adequate.
Fixation
Methods: Using 8 Theil-embalmed specimens, measurements of tarsometatarsal joint dorsal displace-
ment at each ray (1st5th) and 1st2nd metatarsal gaping were made during simulated weight bearing
with sequential ligamentous injury and stabilisation to determine the contribution of anatomical
structures and xation to stability.
Results: At baseline, mean dorsal tarsometatarsal joint displacement of the intact specimens during
simulated weight bearing (mm) was: 1st: 0.14, 2nd: 0.1, 3rd:0, 4th: 0, 5th: 0.14. The 1st2nd
intermetatarsal gap was 0 mm. After transection of the Lisfranc ligament only, there was 1st2nd
intermetatarsal gaping (mean 4.5 mm), but no increased dorsal displacement. After additional
transection of all the tarsometatarsal joint ligaments, dorsal displacement increased at all joints (1st:
4.5, 2nd: 5.1, 3rd: 3.6, 4th: 2, 5th: 1.3). Stabilisation with the home run screw and 4th and 5th ray k-wires
virtually eliminated all displacement. Further transection of the inter-metatarsal ligaments increased
mean dorsal displacement of the 3rd ray to 2.5 mm. K-wire xation of the 3rd ray completely eliminated
dorsal displacement.
Conclusions: The results of this cadaveric study suggest that stabilising the medial cuneiform to the 2nd
metatarsal base combined with stabilisation of the 4th and 5th tarsometatarsal joints with K-wires will
stabilise the 1st and 3rd tarsometatarsal joints if the inter-metatarsal ligaments are intact. Thus 3rd TMTJ
stability should be checked after stabilising the 2nd and 4/5th. Provided the intermetatarsal ligaments
(3rd4th) are intact, the 3rd ray does not need to be routinely stabilised.
2017 Elsevier Ltd. All rights reserved.

Background Post-traumatic arthritis is most common at the base of the

Disruption of the tarso-metatarsal joint (TMTJ Lisfranc)
complex is a potentially devastating injury of the midfoot. These
injuries can be classied into types AC based on the pattern of
injury and degree of TMTJ incongruity [1]. In 1986 Myerson
highlighted the signicant morbidity resulting from these injuries,
reporting that failure to achieve anatomical joint reduction was the
most common reason for poor outcome [1].
* Corresponding author. Present address: Department of Trauma and Orthopae-
dics, Ninewells Hospital, Dundee, DD2 1UB, United Kingdom.
E-mail address: alistairmayne@nhs.net (A.I.W. Mayne).
second metatarsal, suggesting that incongruity is better tolerated
at the medial and lateral columns [2]. Indeed, post-traumatic
arthritis is rare in the 4th and 5th TMTJ which have the most
sagittal plane motion [3].
Treatment has evolved over time. Historically, patients were
treated with either closed or open reduction, with Kirschner wire
xation [4]. However, the emphasis is now on anatomical
reduction of the TMTJs and maintenance of the reduction until
ligamentous stability has been restored. This can be achieved with
either open reduction and rigid internal xation or primary
arthrodesis [5,6].
Fixation usually progresses from the medial to the lateral side.
Various techniques have been described to stabilise the medial and

http://dx.doi.org/10.1016/j.injury.2017.04.003
0020-1383/ 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: A.I.W. Mayne, et al., Stability of Lisfranc injury xation in Thiel Cadavers: Is routine xation of the 1st and 3rd
tarsometatarsal joint necessary?, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.003
G Model
JINJ 7168 No. of Pages 4
2 A.I.W. Mayne et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx
middle columns of the midfoot. Some surgeons advocate trans-
articular screw xation of the 1st and 2nd TMTJs, whereas others
prefer extra-articular xation with either plates or staples [7,8].
Whilst these extra-articular techniques avoid violation of the
articular surface and confer excellent stability, they require
additional larger exposure, longer operating times and more
extensive dissection for subsequent metalwork removal. A trans-
articular Home Run Screw is then usually inserted proximal to
distal from the medial cuneiform to the base of the 2nd metatarsal.
To augment the middle column xation, there is generally also
intra-articular screw xation or extra-articular plate xation of the
3rd TMTJ, with percutaneous Kirschner-wire (k-wire) stabilisation
of the 4th and 5th TMTJs (lateral column).
However, there are a number of challenges to xation of the 3rd
TMTJ, with intra-articular screw xation risking 3rd TMTJ
chondrolysis and osteoarthritis, and extra-articular plating involv-
ing a larger exposure with a longer operating time and need for
later removal. There is no option for extra-articular screw xation
of the 3rd TMTJ and as it is highly prone to post-traumatic arthritis,
any intra-articular screw is best avoided. The usual approach to the
3rd TMTJ involves checking the stability of the 3rd ray after
stabilization of the 2nd TMTJ and often before stabilization of the
4th and 5th TMTJs. No previous studies have investigated the
contribution of isolated home-run screw xation to the stability of
the 1st TMTJ, which we feel is likely to be sufcient with a
functional windlass mechanism. There are also no previous studies
investigating the need for routine stabilization of the 3rd TMTJ.
The aims of this cadaveric study were therefore to determine if
routine xation of the 1st and 3rd TMTJ is necessary, to determine
if a distal to proximal home run screw is adequate and to help
determine the optimal surgical strategy in these challenging
injuries.
Methods
Eight Thiel-embalmed below-knee cadavers were used. None of
the specimens had evidence of previous ankle surgery or trauma.
The dorsal and medial capsule and ligaments of the TMTJ complex
were exposed. Simulated weightbearing measurements, including
dorsiexion of the ankle and mid-foot joints to activate the
windlass mechanism, were taken at each step, with 100Newtons of
weight being applied. Measurement of the amount of 1st2nd
metatarsal gaping and the amount of TMTJ dorsal displacement at
each ray (1st5th) was undertaken following each step. Measure-
ments were taken using a ruler, with three measurements taken
from each specimen and the mean calculated. Baseline measure-
ments were taken prior to any ligamentous or capsule disruption,
then measurements were taken following division of the Lisfranc
ligament (dorsal and plantar) and then following division of the
remaining tarsometatarsal ligaments (dorsal and plantar) and joint
capsules (creating a Myerson type A injury).
Table 1
Mean dorsal displacement and 1st2nd intermetatarsal gap at each stage.
1st TMTJ dorsal 2nd TMTJ dorsal
displacement displacement
Baseline (intact specimens) 0 0.14
Lisfranc Ligament divided 0 0.14
Lisfranc Ligament and Tarso-Metatarsal 4.5 5.1
Ligament divided
Home Run Screw and k-wire stabilisation 0 0
of 4th & 5th TMTJ
2/3/4th Inter-metatarsal ligaments 0 0
divided
Home Run Screw and k-wire stabilisation 0 0
of 3rd, 4th & 5th TMTJ
Please cite this article in press as: A.I.W. Mayne, et al., Stability of Lisfranc injury xation in Thiel Cadavers: Is routine xation of the 1st and 3rd
tarsometatarsal joint necessary?, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.003
The senior authors technique was used to stabilize the injury,
which involved approximately a 3 cm incision over the dorso-
lateral border of the 2nd TMTJ. This incision usually allows
adequate access without the need to dissect the neurovascular
bundle. This exposes the 2nd and 3rd TMTJ and the lateral corner of
the 1st TMTJ and allows easy access for a reverse home-run
screw. The rst step is to accurately reduce the 2nd TMTJ and
transx the joint temporarily using a 1 mm K-wire (essential to
maintain reduction during home-run screw insertion). Next, a
4 mm reverse home-run screw is inserted without counter-sinking
the screws head in order to facilitate screws removal in the future.
The third step is then to check the stability of the 1st TMTJ, as the
home run screw contributes to maintaining the medial arch, which
in-turn re-functions the windlass foot mechanism. The windlass
mechanism is a major contributor the stability of the 1st TMTJ and
therefore the stability of the 1st TMTJ should only be assessed after
stabilizing the 2nd TMTJ and with dorsiexion of the foot to
activate the windlass mechanism [9]. The 4th and 5th TMTJs were
then stabilized using 1.6 mm k-wires and measurements taken.
The inter-metatarsal ligaments between the 2nd to 5th metatarsals
were then divided and measurements were repeated. Finally,
xation of the 3rd TMTJ was performed using a 1.6 mm K-wire and
nal measurements were taken.
Results
Table 1summarises the mean dorsal displacement and 1st/2nd
intermetatarsal gap at each stage. At baseline, the mean dorsal
TMTJ displacement of the intact specimens during simulated
weight bearing was: 1st TMTJ 0.14 mm, 2nd TMTJ 0.1 mm, 3rd TMTJ
0 mm, 4th TMTJ 0 mm, 5thTMTJ 0.14 mm. None of the specimens
had a 1st-2nd intermetatarsal gap. After transection of the Lisfranc
ligament only, there was a mean 4.5 mm of 1st-2nd intermetatarsal
gaping, but no increased dorsal displacement. After additional
transection of all the TMTJ ligaments, dorsal displacement
increased at all joints (1st: 4.5 mm, 2nd: 5.1 mm, 3rd: 3.6 mm,
4th: 2 mm, 5th: 1.3 mm). Stabilisation with the reverse home run
screw and 4th and 5th ray k-wires virtually eliminated all
displacement. However, transection of the inter-metatarsal
ligaments increased mean dorsal displacement of the 3rd ray to
2.5 mm. K-wire xation of the 3rd ray completely eliminated dorsal
displacement. The reverse home run screw and activation of the
windlass mechanism was adequate to stabilize the 1st TMTJ.
Discussion
Although tarsometatarsal joint complex (Lisfranc) injuries are
rare, they are often associated with poor outcomes, especially if
diagnosed late [10] or if there is malreduction of the joint complex
[1]. Therefore there are few, if any, indications for non-operative
management if displacement is present. There is, however,
3rd TMTJ dorsal 4th TMTJ dorsal 5th TMTJ dorsal 1st/2nd Inter-
displacement displacement displacement metatarsal Gap
0.1 0 0.14 0
0.1 0 0.14 4.5
3.6 2 1.3 4.5
0.33 0 0 0
2.5* 0 0 0
0 0 0 0
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A.I.W. Mayne et al. / Injury, Int. J. Care Injured xxx (2017) xxxxxx 3

Fig. 1. The Reverse Home-run screw.

ongoing controversy as to whether open reduction and internal
xation or primary arthrodesis leads to superior outcomes [11].
The TMTJ complex is the articulation between the three
cuneiforms and cuboid proximally and the base of the ve
metatarsal bones distally and represents the junction between the
midfoot and forefoot. The TMTJ complex is made up of bony and
ligamentous elements that combine to give structural support to
the transverse arch of the foot. Intrinsic stability is provided by the
bony architecture. The trapezoidal shape of the middle three
metatarsal bases and their associated cuneiforms produce a stable
transverse roman arch, with the keystone being the 2nd TMTJ a
product of the recessed middle cuneiform. The 5 metatarsal heads
are held together by the deep transverse metatarsal ligaments. The
2nd5th metatarsal bases are held together by intermetatarsal
ligaments but between the 1st and 2nd metatarsals, there is no
inter-metatarsal ligament. Instead, the Lisfranc ligament runs from
the medial cuneiform to the base of 2nd metatarsal and is the
strongest ligament of the TMTJ complex [12]. The plantar
ligaments are stronger than the dorsal ligaments and so the TMTJ
complex is vulnerable to dorsal loading.
The three column classication theory of midfoot injuries was
proposed by Choido and Myerson in 2001 and helps with surgical
planning due to the fact that each column works as a functional
unit and this must be considered when contemplating xation
[13]. The medial column includes the rst metatarsal-medial
cuneiform joint, the middle column includes the second and third
TMTJs as well as the articulations between the middle and lateral
cuneiforms, and the lateral column consists of the articulations
between the fourth and fth metatarsals and the cuboid [14]. The
middle column only has approximately 0.6 mm of dorsal-plantar
sagittal plane motion [3]. The medial column allows approximately
3.5 mm of sagittal movement whereas the lateral column allows an
average of 13 mm of movement in the sagittal plane [3].
Not all TMTJ complex injuries are alike. The results of this
cadaveric study suggest that stabilising the medial cuneiform to
the 2nd metatarsal base combined with stabilisation of the 4th and
5th TMTJs with K-wires will stabilise the 3rd TMTJ if the inter-
metatarsal ligaments are intact. Thus 3rd TMTJ stability should be
assessed after stabilisation with a home run screw and K-wires to
the 4th and 5th rays. Provided the 3rd and 4th intermetatarsal
ligaments are intact, our results indicate that the 1st and 3rd TMTJs
do not need to be routinely stabilized in total incongruity type A
injuries.
Our results also indicate that adequate stabilisation can be
achieved with a so-called Reverse home-run screw inserted
distal to proximal from the base of the 2nd metatarsal to the
medial cuneiform as illustrated in Fig. 1. We feel this is a more
tolerant technique, with a larger margin of error, when aiming

Fig. 2. Standard Home Run Screw.

Please cite this article in press as: A.I.W. Mayne, et al., Stability of Lisfranc injury xation in Thiel Cadavers: Is routine xation of the 1st and 3rd
tarsometatarsal joint necessary?, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.003
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Fig. 3. Comparison of both techniques with eccentric entry point.
from the smaller 2nd metatarsal into the larger medial cuneiform,
which provides a greater arc of possible screw placement with a
central entry point.
Contrast this with the standard home run screw technique as
shown in Fig. 2 which is technically more challenging, with a
smaller arc of possible screw placement. Furthermore, there is an
increased risk of missing the target bone (2nd metatarsal) if the
medial cuneiform entry point is not central as seen in Fig. 3.
We feel a distal to proximal home run screw has advantages of
allowing easier placement with greater precision and also
minimises the soft tissue dissection. The combination of a distal
to proximal home run screw and the lack of routine stabilization of
the 3rd TMTJ is likely to lead to an overall reduction in surgical time
and reduced soft tissue trauma, with this concept in line with the
philosophy of Lisfranc himself who once wrote surgery is bright
when operating, but it is still brighter when there is no blood and
mutilation and yet leads to the patients recovery! [15].
As this was a cadaveric study with limited specimen numbers,
the results must be interpreted with caution. Thiel embalmed
cadavers have almost life-like tissue exibility and more real tissue
characteristics compared to traditional formaldehyde embalming
[16]. Nonetheless, further work is required to investigate this
technique in the clinical setting.
Conclusions
The results of this cadaveric study suggest that stabilising the
medial cuneiform to the 2nd metatarsal base combined with
Please cite this article in press as: A.I.W. Mayne, et al., Stability of Lisfranc injury xation in Thiel Cadavers: Is routine xation of the 1st and 3rd
tarsometatarsal joint necessary?, Injury (2017), http://dx.doi.org/10.1016/j.injury.2017.04.003
stabilisation of the 4th and 5th TMTJs with K-wires will stabilise
the 1st TMTJ and the 3rd TMTJ if the inter-metatarsal ligaments are
intact.
Conict of interest
There are no conicts of interest for any of the authors to
declare.
Authors contribution
All authors were fully involved in the study and preparation of
the manuscript. The material has not been submitted for
publication elsewhere
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