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Suture button fixation treatment of chronic Lisfranc injury in professional dancers and high-level athletes.

Lisfranc injuries are a common problem in the trauma field. However, the diagnostic findings may be subtle in late presentation of a dancer or other athlete. Often the diagnosis of a midfoot sprain is made, and persistent subtle Lisfranc joint tenderness may be noted. (1,2) In dancers, this can be seen with persistent difficulty achieving the en pointe position (weightbearing on extended toes in full plantarflexion). The Lisfranc ligament has been shown to play an important role in stabilizing the pointe position, and its disruption can be associated with significant changes in relative alignment while en pointe, as well as destabilization of the midfoot without the pointe shoe. (3) These patients will have an inability to perform some or all dance activities. High level non-dancing athletes generally present with persistent pain and tenderness at the Lisfranc joint despite refraining from activity for a period of time during which a midfoot sprain would be expected to heal. (2,4)

Lisfranc injury without gross displacement is a subtle diagnosis and easily missed. (5) In addition to some tenderness overlying the Lisfranc space, slight diastasis may be noted on weightbearing x-ray, though plain films may also appear normal and the injury may only be visualized by MRI. (2,6) Dancers specifically can present with many midfoot problems associated with the strain of the pointe position, which can confound the subtle findings of this injury. The differential diagnosis frequently includes second metatarsal stress fracture, which is a common injury in dancers and especially difficult to differentiate from Lisfranc injury. (3) However, location of tenderness medially at the Lisfranc space suggests Lisfranc injury is more likely than a stress fracture. Although not routinely employed by the investigators, local injection of lidocaine into the Lisfranc space can be used as a supplementary procedure to test for temporary pain relief.

Current standard of care for a displaced Lisfranc fracture is open reduction with internal fixation or primary fusion. (7) Often subtle injuries do not respond to nonoperative treatment, resulting in a fusion or use of a screw. This presents specific challenges to professional dancers or high-level athletes, as they often cannot tolerate tarsometatarsal fusion or screw fixation. Subsequent arthritis in the second tarsometatarsal joint and Lisfranc joint often seen after screw fixation (8) can be career ending. (9)

Though screw fixation has been shown to have potentially superior fixation characteristics, (10) suture button constructs have been described as being effective in the treatment of Lisfranc injury and repair. (11) We report treatment of Lisfranc injuries with suture button fixation in seven patients who were either professional dancers or high-level athletes to discern the viability of a more flexible repair construct given unique demands for flexibility and tolerance to stress at that joint.


Inclusion criteria were either professional dancers or high-level (Division I College) athletes who had been diagnosed with Lisfranc injury by way of complaints isolated to directly over the Lisfranc space and had failed conservative management after sustaining a midfoot sprain; specifically, direct point tenderness over the Lisfranc space on clinical exam, either at the first or second tarsometatarsal joint, and either minimum of 2 mm diastasis on weightbearing plain film or suggestive signal changes on MRI, with no signal changes at the base of the second metatarsal as would be more suggestive of stress fracture. Surgical indication was the failure of conservative management, which was a minimum 6-month cessation of all athletic activities and use of a walking boot for any weightbearing, and the absence of degenerative changes or stress fracture on x-ray or MRI. Patients were evaluated and AOFAS midfoot score calculated preoperatively and at the 6-month postoperative visit, prior to return to activity.

An ankle tourniquet was used. The articular margins of the middle cuneiform, medial cuneiform, first metatarsal, and second metatarsal were drawn on the skin to help with placement of the incision and the Kirschner wire guide pin. A dorsal incision of approximately 2 cm was made. Careful attention was used to avoid injury of the dorsal cutaneous nerve, which is frequently visualized with this approach (12) and can cause numbness and dysesthesia if damaged (Fig. 1). The fascia over the extensor hallucis longus (EHL) and extensor hallucis brevis (EHB) tendons was incised. Just below these tendons, the neurovascular bundle was gently mobilized and carefully protected. The Lisfranc ligament was identified deep to the bundle and assessed for laxity with a Freer elevator. Ability of the Freer elevator to pass between the medial cuneiform and base of second metatarsal with limited restriction was considered, by the investigators, to be consistent with sufficient laxity of the ligament.

Under fluoroscopic imaging, 1.6 mm Kirschner wires were placed from the medial cuneiform toward the second metatarsal (Fig. 2). This trajectory was chosen because the third metatarsal can often block access to the reverse trajectory. Ideally the space between the second metatarsal and middle cuneiform would be bisected. The end of the K-wire was intended to lie in the space between the second and third metatarsals; too proximal placement may not allow the button to sit flush on the bone and may not provide adequate compression. Careful attention was given not to have the medial starting point at the level of the tibialis anterior tendon, nor too close to the first tarsometatarsal joint, which could fracture into the joint or result in less stable fixation. Fluoroscopic imaging confirmed appropriate placement of this K-wire. A 2.7 cannulated drill was then used from the medial to lateral (medial cuneiform to second metatarsal) direction.

After the drill hole was created a suture lasso was positioned (Fig. 3). The suture button was advanced from the second metatarsal into the medial cuneiform (a small incision was often made to facilitate and confirm that the medial button was lying flat, and there was no entrapment of the tibialis anterior tendon). The suture but ton was then tied against the second metatarsal. The direction of insertion of the button was specifically chosen such that the bulk of the knot was not tied on the surface of the medial cuneiform, which can be irritating and cause a significant problem with pointe shoes (Fig. 4). Fluoroscopic imaging in the lateral projection confirmed that the suture button placement was not too dorsal (Figs. 5 and 6). Excessive dorsal placement could potentially lead to cortical fracture, yet a slightly dorsal position can be advantageous for ease of knot tying. Augmentation of the dorsal capsule can be achieved with non-absorbable sutures but was not done in this series. A running subcuticular closure was performed for cosmetic benefit.

Postoperatively, the patient was placed in a short leg splint and kept non-weightbearing for 2 weeks. After 2 weeks, the splint was removed, and the patient was placed in a CAM Walker Boot for gentle active or passive ankle range of motion. Nonweight-bearing was continued for 4 additional weeks (6 weeks total). The patient was then placed in a shoe with an arch support and allowed to transition off crutches gradually over the course of 2 weeks. For dancers, barre work was allowed after 3 months and return to center (full participation) at 6 months. For the other athletes, low impact training was allowed at 3 months, and gradual return to full training and participation at 6 months.


We treated seven patients (six female and one male) with the suture button device (Arthrex Mini TightRope[R] 2.7 mm AR-8911DS, Naples, FL, USA). Five patients were professional elite-level ballet dancers, and two were NCAA Division I soccer players. All patients presented to the lead investigator after failing a minimum of 6 months of conservative management. Average age of the patients at surgery was 24.6 years, with a range from 18 to 29 years. Average duration of conservative treatment for these athletes was 14 months, with a range from 6 to 20 months. All patients were operated on by one of two attending surgeons with experience using the suture-button device. There were no wound healing problems, no incidents of wound dehiscence, or other early complications. Immediate postoperative films demonstrated less than 1 mm diastasis at the Lisfranc space, with joint surfaces congruent and symmetrical. All patients returned to full activity with no residual deficits by 6 months. Preoperative AOFAS midfoot score was 65 (range: 59 to 72), with most significant complaints of moderate pain and pain with activities of daily living. AOFAS midfoot score was 97 (range: 90 to 100), measured at the latest follow-up visit and after the patient had returned to full activities. A minimum of 1-year follow-up was required for inclusion in the study, with an average of 25 months (range: 15 months to 3.75 years).

At the most recent follow-up, all patients were participating in full professional dance or sporting activities at pre-injury level. Plain films taken at the time showed no significant changes from immediate postoperative films, as assessed by attending surgeons. There was no displacement of the suture button device within the bone, bone erosion, device cut-out, or fracture.


Lisfranc injury in the population of high-level athletes and dancers is a difficult problem to treat. The diagnosis is often subtle and delayed, and the demands of this population are such that standard of care treatment with screw fixation and fusion is not well tolerated. This population predictably places higher demands on the Lisfranc joint due to the rigor of their activities. In dancers, the specific stresses of positioning in pointe shoes seems to place them at high risk for post traumatic arthritis and complications such as hardware breakage and failure. For this population, suture button fixation may represent an effective alternative to screw fixation and fusion, allowing them to return to full participation and meet the demands of their respective activities.

The goal of fixation has previously been to reduce motion and achieve rigid fixation across the Lisfranc space to allow for primary bone healing by fusion. However, biomechanical studies have shown that measurable motion occurs at the Lisfranc joint in the intact, physiologic state. (13) While there is no evidence that the general population is intolerant of fusion at the Lisfranc joint, high-level athletes and dancers stress this joint uniquely and require a greater degree of flexibility. Thus, primary fusion is generally not a viable solution, as it nearly mandates permanent cessation of those activities and thus represents a career ending condition. In rigid screw fixation, even with subsequent screw removal to avoid healing by fusion of this joint, postoperative arthritis is a well-recognized phenomenon, which again could be career ending for this population.

This fact prompted investigation into non-rigid fixation, the so-called "flexible fixation," with a suture button device across the joint for the subtle sprain that failed conservative management. The goal of this fixation is to restore pre-injury level of motion (11) while preventing excessive motion associated with the ligamentous disruption suffered and subsequent associated pain and stresses within the midfoot. Fixation with the suture button device has been shown to reduce motion at this joint to pre-injury levels and is similar to screw fixation with regard to axial and abduction stresses. (14,15) The restriction of motion to physiologic level with suture button, coupled with the flexibility principle allowing for maintenance of that baseline motion, may reduce stress on adjacent joints.

The suture button fixation has previously been described in two case series for the treatment of Lisfranc injuries. (11,16) Our results are similar in that no patients experienced complications, and all were able to return to previous level of activity within 6 months. Our series is unique in the addition of dancers and exclusive inclusion of high-level athletes, supporting the conclusions of the previous case series that this method of fixation is effective, reproducible, and prevents the need for subsequent operative procedures due to hardware complications. Additionally, this fixation may provide an advantage over rigid screw fixation for dancers, as the rigid screw fixation must be removed prior to resumption of dance activities. It may also provide the benefit of restoration of physiologic motion across the Lisfranc joint.

Limitations of this study include the small number of patients, operated on by one of two surgeons at a single institution, with no blinding or independent assessment of outcomes and relatively short-term follow-up. Also, the lack of follow-up MRIs limits the conclusions that can be drawn regarding how the joint is healing with the utilization of the suture button device. Long-term studies are needed to elucidate the viability of this fixation when compared to screw fixation or arthrodesis, as well as potential complications unique to flexible fixation such as potential erosion of bone, fracture, or fixation cut-out, which may be significant issues in the female dancer with osteopenia. Promising newer techniques, such as dorsal bridge plating, a technique used by both senior investigators for acute displaced injuries, may be an alternative to suture button fixation. However, the benefits of dorsal bridge plating may be offset by the requirement of plate removal prior to resumption of dance activities.


Suture button fixation represents a viable option for restoration of Lisfranc ligament function in the high level athlete or dancer who is intolerant of rigid screw fixation. Future studies may elucidate the specific function of the suture button in these patients as a supplemental ligament or support strata for healing by fusion, as well as the long-term outcomes of this type of fixation.

Timothy Charlton, M.D., and David B. Thordarson, M.D., Cedars Sinai Medical Center, Los Angeles, California. Chelsea Boe, M.D., Mayo Clinic, Department of Orthopaedic Surgery, Rochester, Minnesota.

Correspondence: Timothy Charlton, M.D., Cedars Sinai Medical Center, 444 South San Vincente Boulevard, Los Angeles, California 90048; timothy.charlton@


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Author:Charlton, Timothy; Boe, Chelsea; Thordarson, David B.
Publication:Journal of Dance Medicine & Science
Article Type:Report
Date:Oct 1, 2015
Previous Article:Dancing Through It: My Journey in the Ballet.
Next Article:Epidemiological review of injury in pre-professional ballet dancers.

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