Working Diagnosis:
Lisfranc injury

Treatment:
When options of surgical exploration were discussed, the patient and her mother made it clear that they were not comfortable with pursuing such invasive methods of treatment. A primary concern of theirs was the recovery time required for such a procedure, due to the remainder of the volleyball season still being in play. The patient also did not want to miss the upcoming basketball season, which would have started during the recovery period from a surgical procedure. Alternative methods of treatment were sought out, which led to discussion of the risks, benefits, indications, contraindications, and alternatives to PRP treatment. After careful consideration, the patient and her parent agreed to attempt PRP therapy.

Outcome:
The PRP treatment was conducted a week after. Approximately 50cc of blood was drawn from the arm and placed into a tube. The tube of blood was placed into the Arthrex ACP Double Syringe System to be centrifuged and separated. After 30 minutes of spinning, the machine separated the drawn blood into red blood cells, platelet-poor plasma, and platelet-rich plasma. The platelet-rich plasma was drawn up into a syringe. Local anesthetic consisting of lidocaine was injected at the site of injury, followed by injection of the PRP. After 15-20 minutes of rest, the patient was allowed to leave the office and advised to continue refraining from strenuous activity. A follow-up appointment was scheduled for 4 weeks in the future. At the following visit, the patient reported that her symptoms had almost totally resolved. She was cleared from any restrictions regarding her activity.
In the short-term follow-up from procedure, the patient showed almost complete improvement from when she was initially treated. The PRP procedure was completed within an hour and utilized autologous blood for healing purposes. To the general population, this treatment method may appear more holistic due to the lack of foreign substances entering the body for therapeutic measures. The procedure was also more cost-effective than a surgical procedure would have been.

Author's Comments:
Dr. Jacques Lisfranc was a French surgeon who served in the army under the Napoleon regime. While in the military, he noticed that many soldiers were suffering from midfoot injuries severe enough to require amputations. These injuries mostly occurred during battle when soldiers fell from their horses while getting their midfoot stuck in the stirrups. The high level of force impacting the ligamentous attachment between the metatarsals and their respective tarsal bones caused severe sprains and displacement. Today, the injury typically occurs during competition when the foot is plantar flexed and abducted or adducted. In this position, any significant force being applied to the midfoot region has the potential to cause impressionable damage due to the laxity of the interosseous ligaments between the tarsal and metatarsal bones.

The common subtle findings in initial evaluation of a Lisfranc injury can lead to delayed diagnosis and inappropriate treatment. These include radiographs showing non-specific soft tissue swelling and physical exam findings like inability to bear weight and tenderness upon palpation. When there is high clinical suspicion, magnetic resonance imaging is indicated for more thorough analysis of involved structures. While younger people tend to respond better to conservative measures of treatment like resting and bracing the affected foot, additional methods of treatment may be implicated if optimal recovery is not attained. The most common invasive intervention for treatment is a closed reduction with percutaneous screw fixation or open reduction surgical procedure.

Platelet-rich plasma therapy has gained popularity in recent years due to its successful application to various types of sports injuries. PRP is an outpatient procedure that is far less invasive than surgical methods of treatment. The procedure involves the physician drawing blood from the arm into a syringe and hooking the syringe of blood to a centrifuge machine. The centrifuge separates the platelet-rich plasma from the other components of the blood so that the physician can aspirate it. The platelet-rich plasma is then injected back into the patient at the site of injury and surrounding structures so that the regenerative growth factors associated with platelets, including VEGF, FGF, PDGF, EGF, and TGF-B, can promote healing.

Lisfranc injuries are often susceptible to receiving delayed treatment due to misdiagnosis based on subtle radiographic findings. The delayed or improper treatment of this injury can lead to chronic arthritic changes and ruin a patient’s athletic aspirations.

Limitations to PRP therapy for an injury like this were exhibited as well. The patient experienced profound pain shortly after receiving the PRP injection at the site of injury, lasting about 20 minutes. The cost was much cheaper than that of surgery but was also much more expensive than conservative measures. Patients who are not under a time crunch to recover may benefit from longer periods of rest and physical therapy rather than PRP.

Based on the current literature and the findings from this case, Platelet-Rich Plasma therapy appears to be a viable solution for young athletes with Lisfranc injuries refractory to conservative measures of treatment. PRP is a relatively quick, cost-effective, and minimally invasive procedure that more young athletes should consider if their injuries can benefit from it. Further studies for PRP treatment for various types of athletic injuries, specifically Lisfranc injuries in different age populations, are indicated.

Editor's Comments:
Sprains of the lisfranc joint can occur in young athletes that participate in sports with jumping and landing. More severe injuries seen in this age group with landing from a height, for example fall out of a tree. Findings can be subtle and missed. So, a high index of suspicion is necessary. Be especially suspicious if you appreciate bruising on the plantar aspect of the foot (not mentioned in this athlete).
The mechanism of injury includes motor vehicle accidents, falls from height, and athletic injuries. Usually patients will experience indirect rotational forces and axial load through hyper-plantarflexed forefoot as in jumping and landing in sports such as volleyball and basketball. Also, these can occur in hyperflexion/compression/abduction movements exerted on the forefoot and transmitted to the tarsal-metatarsal articulation. In severe situations, the metatarsals are displaced in the dorsal and lateral direction.
A Lisfranc injury is a tarsometatarsal disruption involving fracture and or sprain between the articulation of the medial cuneiform and base of the second metatarsal. Often this is traumatic in nature. Widening of the interval between the 1st and 2nd ray on standing AP x-ray supports the diagnosis. CT scans can be helpful if fracture is suspected. An MRI can confirm the diagnosis of ligamentous injury. Treatment is dependent on extent of the injury and involvement of bony fracture and or ligament tear as well as stability, but generally operative with either ORIF or arthrodesis considered.
Midfoot injuries such as Lisfranc sprains (fractures) are fraught with complications and potential poor prognosis. There is significant variability regarding return to full activity given heterogenous group of patients in nearly all studies. Complete sprains with instability on weight-bearing have a poor prognosis compared to stable sprains. Non-displaced stable fractures of the cuniform and second metatarsal tend to do better than unstable fractures. However, non-union can occur. In the military population, at 3 year follow-up, 70% patients undergoing ORIF or primary arthrodesis were able to resume occupationally required daily running. Poor prognostic is associated with missed diagnosis, therefore a high level of suspicion is critical.

References:
Burroughs KE, Reimer CD, Fields KB. Lisfranc injury of the foot: a commonly missed diagnosis. American Family Physician. 1998 Jul;58(1):118-124.
DeOrio M, Erickson M, Usuelli FG, Easley M. Lisfranc injuries in sport. Foot Ankle Clin. 2009 Jun;14(2):169-86. Doi: 10.1016/j.fcl.2009.03.008. PMID: 19501801.
Lewis JS Jr, Anderson RB. Lisfranc Injuries in the Athlete. Foot Ankle Int. 2016 Dec;37(12):1374-1380. doi: 10.1177/1071100716675293. PMID: 27899721.
“Platelet Rich Plasma.” Arthrex, Inc., www.arthrex.com/orthobiologics/platelet-rich-plasma.
“Platelet-Rich Plasma (PRP) Treatment.” Johns Hopkins Medicine, www.hopkinsmedicine.org/health/treatment-tests-and-therapies/plateletrich-plasma-prp-treatment.
Solan MC, Moorman CT 3rd, Miyamoto RG, et al. Ligamentous restraints of the second tarsometatarsal joint: a biomechanical evaluation.Foot Ankle Int 2001; 22:637.
Watson, Troy S. MD; Shurnas, Paul S. MD; Denker, Jacques Treatment of Lisfranc Joint Injury: Current Concepts, American Academy of Orthopaedic Surgeon: December 2010 - Volume 18 - Issue 12 - p 718-728
Koehler, L, BR Waterman , NA Kusnezov , JA Blair , PJ Belmont, J D Orr.Occupational Outcomes and Return to Running After Operative Management of Lisfranc Injuries in a High-Demand Population. Foot Ankle Spec. 2020 Jun 9.

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