Revista de Medicina Desportiva (English) March 2018 - Page 26

• type 2 – diastasis between 1 and 5 mm exists between the first and second metatarsals without longi- tudinal arch in the lateral X-ray • type 3 – presents diastasis and longitudinal arch collapse. In the acute phase, the patient presents weight-bearing midfoot pain and edema, with partial or total gait limitation. Structural damage is strongly suspected with the pres- ence of ecchymosis in the plantar region. The “piano key test” may pre- sent a positive sign, consisting of a dorsal prominence of the metatarsal bases, which is reduced with exer- tion of plantar pressure. 10-12 In an imaging perspective, regard- ing the anteroposterior X-ray, the medial side of the second metatarsal should be aligned with the medial side of the intermediate cuneiform, as well as in the oblique X-ray, the medial side of the cuboid should intersect the medial side of the fourth metatarsus. In the weight bearing lateral X-ray, an alignment must exist between the dorsal region of the first metatarsus and the medial cuneiform. Contralateral comparison of the foot should be obtained in order to improve diag- nostic acuity. In addition, the pres- ence of diastasis in the basal region should raise suspicion of possible injury whenever the value is greater than or equal to 2mm. Stress radiog- raphy has a controversial role in the literature. 10,13 Computed tomography may also play a relevant role, espe- cially in more complex bone lesions typical of high-energy trauma. 13-15 Magnetic resonance imaging plays a preponderant role in ligament inju- ries, in both the characterization and in the identification of the injury. 10,13 Conservative treatment consists of a suropodalic cast with immobi- lization or with orthosis during six weeks without load, being that from this point on, and depending on the patient’s pain symptoms, gradual progression of physical activity may be allowed, accompanied by physi- cal therapy, or if painful symptoms persist, an additional period of fo ur weeks with a new orthosis. 9,16 Conservative treatment in the sports population remains controversial and is reserved for stable and non- dislocated injuries. Regarding this injury, few studies exist in the sports population. Several authors, how- ever, indicate this method as suc- cessfully compatible, although more recently it has been associated with a higher risk of failure. 9,16-18 Surgical treatment in the sports population is presented with good results in the literature with high rates of return to sport activity. Some controversy exists as to the type of fixation used (screws, plate and screws or elastic suture-button fixation). Biomechanically, there doesn’t seem to apparently be a dif- ference between fixation only with screws (Figure 4) or with plate and screws. However, fixation with an elastic suture-button method yields conflicting results in the literature. A pertinent and sustained concern in the literature is related to the joint damage caused by transarticu- lar screws and the evolution of the degenerative changes, as well as the capacity to achieve an anatomical reduction in both techniques, with the utilization of plaque and screws being sometimes described as a bet- ter reduction method. 10,19,20 Primary arthrodesis is described in the literature in several circumstances, including the sports population, offering contrast- ing results. One of the underlying problems regarding this issue is that in the sports population most of the injuries are of a ligamentous nature and on several occasions the results described in the litera- ture refer to populations with bony lesions resulting from high energy trauma (contrary to most common sports accidents). The opinion of the authors regarding primary arthro- desis in purely ligamentous lesions in the athletic population is that it should not be performed. This opinion is supported by the scientific literature. 10,21 Post-operative rehabilitation presents highly variable values ​​ in the literature (between 3 and 8 weeks) with no load, as well as a highly discrepant time in return to sport activity (3 to 7 months). The literature does not present uniform guidelines regarding the extraction of the implanted material, being this a controversial issue. However, it is usually performed at approximately six months after surgery, depend- ing on the need to remove the implanted material. 10,21-23 In conclusion, it should be noted that the Lisfranc lesion terminol- ogy comprises a diverse spectrum of lesions, which in itself reveals the complexity of the subject. These injuries can bring about instabil- ity and deformity, which will cause joint degeneration with devastating consequences for the athlete. It is of special importance to note that the role of the clinician is highly rel- evant in the identification of typical ligament subtle lesions in the ath- letic population, since these are pre- cisely those that are more difficult to Figure 2 – Exemplification of the classic model of the mechanism of injury. Figure 3 – Radiograph of a foot with a Lisfranc lesion. Fugura 4 – Radiograph of a foot after surgical treatment. 24 march 2018 www.revdesportiva.pt