The role of three dimension computed tomography in Lisfranc injury diagnosis

Essa, Ahmad; Levi, Almog; Ron, Tzvi Guy; Ner, Eran Beit; Finestone, Aharon S.; Tamir, Eran

doi:10.1016/j.injury.2022.07.032

Cited by 8 publications

(19 citation statements)

References 18 publications

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“…Two-dimensional CT scans are widely available and can be helpful, but reading them may be beyond the ability of a traumatologist without dedicated training in foot and ankle injuries. For this reason, 3D CT images are worth exploring, but only limited work is available on this promising avenue of inquiry [3]. We performed a diagnostic study evaluating three findings on 3D CT: the Mercedes sign, the peeking metatarsal sign, and the peeking cuneiform sign.…”

Section: Discussionmentioning

confidence: 99%

“…The evaluation of the 3D CT model enables realistic and structural visualization of the scanned foot and facilitates better injury evaluation and diagnosis. In a recent study, the use of 3D CT combined with 2D CT was helpful, increasing the sensitivity of Lisfranc injury diagnosis from 47% to 85% [3]. However, no specific radiologic features or practical techniques on how to properly use 3D CT were described in that study.…”

Section: Discussionmentioning

confidence: 99%

“…MRI showed a sensitivity of 90% in the diagnosis of Lisfranc injuries; however, it often results in false-positives and is less available than CT [1,10]. The recent introduction of threedimensional (3D) visualization of CT in the diagnosis of Lisfranc injuries has led to better injury visualization and enhanced diagnostic reliability [3]. In a recent study, the combination of two-dimensional (2D) and 3D CT in the diagnosis of Lisfranc injuries led to improved diagnostic reliability compared with 2D CT alone (85% versus 45%) [3].…”

Section: Introductionmentioning

confidence: 99%

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Lisfranc Injury Diagnosis: What Is the Diagnostic Reliability of New Radiographic Signs Using Three-dimensional CT?

Tamir

Essa

Levi

et al. 2023

Clin Orthop Relat Res

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Background Up to one-third of Lisfranc injuries (an injury affecting the normal stability, alignment, and congruency of the tarsometatarsal joints) are misdiagnosed. Delayed diagnosis and improper treatment may lead to long-term, irreversible sequela and functional disability. Recently, the employment of three-dimensional (3D) CT demonstrated higher diagnostic reliability, but there is limited evidence on this, and radiologic features of Lisfranc injuries when using this diagnostic modality are not well described. Question/purpose What is the diagnostic performance of several novel radiographic signs on 3D CT when evaluating for Lisfranc injury, namely the Mercedes sign, the peeking metatarsal sign, and the peeking cuneiform sign, and what is the interobserver and intraobserver reliability of those diagnostic signs? Methods In this retrospective, diagnostic study, video clips of 3D CT reconstructions of 52 feet with intraoperatively confirmed Lisfranc injuries and 50 asymptomatic feet with a normal appearance of the tarsometatarsal joints, as ascertained by a subspecialty-trained foot and ankle surgeon and a musculoskeletal radiologist, were analyzed by two foot and ankle specialists and three orthopaedic residents twice each, with a washout period of 2 weeks. Among the 52 patients with intraoperative evidence of Lisfranc injury, there were 27 male patients and 25 female patients, with a median (IQR) age of 40 years (23 to 58); among the 50 controls, there were 36 male and 14 female patients, with a median age of 38 years (IQR 33 to 49). For each video clip, the presence of all three radiographic signs was documented (each sign was rated in a binary yes/no fashion). Before the evaluations, all observers underwent a short training session by the head of the foot and ankle department. Later, these reading were used to assess for the sensitivity, specificity, and area under the receiver operating characteristic curve in terms of Lisfranc diagnosis against the gold standard of intraoperative testing of tarsometatarsal joint stability. Intraoperatively, the congruency and stability of the second tarsometatarsal joint had been evaluated by direct visualization and by the insertion of a probe into the joint between the base of the second metatarsus and the medial cuneiform and twisting the probe to assess for stability. The individuals evaluating the video clips were unaware of the surgically obtained diagnosis at the time they performed their evaluations. Results All 3D radiographic signs that were examined had excellent diagnostic reliability in terms of sensitivity and specificity, ranging from 92% to 97% and from 92% to 93%, respectively. When assessing the association between the suggested 3D radiographic signs and Lisfranc injury diagnosis as a function of the area under the receiver operating characteristic curve, the Mercedes sign demonstrated a higher area under the curve than the other signs did (0.91 versus 0.87 versus 0.8; p < 0.001). The mean intraobserver and interobserver reliability (kappa) values were excellent for all 3D radiographic signs that were evaluated. Conclusion The proposed radiographic findings demonstrated excellent diagnostic performance and were repeatable within and among observers. Three-dimensional CT radiographic signs could function as a valuable diagnostic tool for the evaluation and initial screening for Lisfranc injury in the acute injury phase because obtaining AP bilateral standing radiographs of the foot is often impractical in the acute setting. Further research and comparison with AP weightbearing radiographs of the bilateral feet may be warranted. Level of Evidence Level III, diagnostic study.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Lisfranc Injury Diagnosis: What Is the Diagnostic Reliability of New Radiographic Signs Using Three-dimensional CT?

Tamir

Essa

Levi

et al. 2023

Clin Orthop Relat Res

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“…fractures, joint comminution, and minor degrees of joint subluxation that may be missed on radiographs 35 , and 3dimensional reconstructions improve diagnostic accuracy and reliability compared with 2-dimensional interpretation 36 . Recognition of articular injury may aid in surgical decision making when considering primary arthrodesis (PA).…”

Section: Ct Is Valuable In Detecting Occultmentioning

confidence: 99%

“…If weight-bearing radiographs are not tolerated or if these are normal despite ongoing suspicion, cross-sectional imaging including computed tomography (CT) or magnetic resonance imaging (MRI) may be helpful. CT is valuable in detecting occult fractures, joint comminution, and minor degrees of joint subluxation that may be missed on radiographs 35 , and 3-dimensional reconstructions improve diagnostic accuracy and reliability compared with 2-dimensional interpretation 36 . Recognition of articular injury may aid in surgical decision making when considering primary arthrodesis (PA).…”

Section: Investigationsmentioning

confidence: 99%

Management of Lisfranc Injuries

et al. 2023

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There is a spectrum of midtarsal injuries, ranging from mild midfoot sprains to complex Lisfranc fracture-dislocations.Use of appropriate imaging can reduce patient morbidity, by reducing the number of missed diagnoses and, conversely, avoiding overtreatment. Weight-bearing radiographs are of great value when investigating the so-called subtle Lisfranc injury.Regardless of the operative strategy, anatomical reduction and stable fixation is a prerequisite for a satisfactory outcome in the management of displaced injuries.Fixation device removal is less frequently reported after primary arthrodesis compared with open reduction and internal fixation based on 6 published meta-analyses. However, the indications for further surgery are often unclear, and the evidence of the included studies is of typically low quality. Further high-quality prospective randomized trials with robust cost-effectiveness analyses are required in this area.We have proposed an investigation and treatment algorithm based on the current literature and clinical experience of our trauma center.

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