Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Archives of Orthopaedic and Trauma Surgery
Published in: Archives of Orthopaedic and Trauma Surgery 10/2020

Open Access 01-10-2020 | Computed Tomography | Trauma Surgery

Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries

Published in: Archives of Orthopaedic and Trauma Surgery | Issue 10/2020

Login to get access

Abstract

Background

Injury of the tarsometatarsal (TMT) joint complex, known as Lisfranc injury, covers a wide range of injuries from subtle ligamentous injuries to severely displaced crush injuries. Although it is known that these injuries are commonly missed, the literature on the accuracy of the diagnostics is limited. The diagnostic accuracy of non-weight-bearing radiography (inter- or intraobserver reliability), however, has not previously been assessed among patients with Lisfranc injury.

Methods

One hundred sets of foot radiographs acquired due to acute foot injury were collected and anonymised. The diagnosis of these patients was confirmed with a CT scan. In one-third of the radiographs, there was no Lisfranc injury; in one-third, a nondisplaced (< 2 mm) injury; and in one-third, a displaced injury. The radiographs were assessed independently by three senior orthopaedic surgeons and three orthopaedic surgery residents.

Results

Fleiss kappa (κ) coefficient for interobserver reliability resulted in moderate correlation κ = 0.50 (95% CI: 0.45– 0.55) (first evaluation) and κ = 0.58 (95% CI: 0.52–0.63) (second evaluation). After three months, the evaluation was repeated and the Cohen’s kappa (κ) coefficient for intraobserver reliability showed substantial correlation κ = 0.71 (from 0.64 to 0.85). The mean (range) sensitivity was 76.1% (60.6–92.4) and specificity was 85.3% (52.9–100). The sensitivity of subtle injuries was lower than severe injuries (65.4% vs 87.1% p = 0.003).

Conclusions

Diagnosis of Lisfranc injury based on non-weight-bearing radiographs has moderate agreement between observers and substantial agreement between the same observer in different moments. A substantial number (24%) of injuries are missed if only non-weight-bearing radiographs are used. Nondisplaced injuries were more commonly missed than displaced injuries, and therefore, special caution should be used when the clinical signs are subtle.

Level of evidence

III.
Literature
1.
2.
3.
Arntz CT, Veith RG, Hansen ST Jr (1988) Fractures and fracture-dislocations of the tarsometatarsal joint. J Bone Joint Surg 70(2):173–181PubMedCrossRef
4.
Burstein AH (1993) Do they work and are they useful? JBJS 75(12):1743–1744CrossRef
5.
Caro T, Roper R, Young M, Dank G (1979) Inter-observer reliability. Behaviour 69(3):303–315
6.
Chiodo CP, Myerson MS (2001) Developments and advances in the diagnosis and treatment of injuries to the tarsometatarsal joint. Orthop Clin N Am 32(1):11–20CrossRef
7.
Coss LHS, Usnr MC, Manos LRE et al (1998) Abduction stress and AP weightbearing radiography of purely ligamentous Injury in the tarsometatarsal joint. Foot Ankle Int 19(8):537–541PubMedCrossRef
8.
Crates JM, Barber FA, Sanders EJ (2015) Subtle Lisfranc subluxation: results of operative and nonoperative treatment. J Foot Ankle Surg 54(3):350–355PubMedCrossRef
9.
Curtis MJ, Myerson M, Szura B (1993) Tarsometatarsal joint injuries in the athlete. Am J Sports Med 21(4):497–502PubMedCrossRef
10.
11.
Eliasziw M, Young SL, Woodbury MG, Fryday-Field K (1994) Statistical methodology for the concurrent assessment of interrater and intrarater reliability: using goniometric measurements as an example. Phys Ther 74(8):777–788PubMedCrossRef
12.
Faciszewski T, Burks RT, Manaster BJ (1990) Subtle injuries of the Lisfranc joint. J Bone Joint Surg 72(10):1519–1522PubMedCrossRef
13.
Foster SC, Foster RR (1976) Lisfranc's tarsometatarsal fracture—dislocation. Radiology 120(1):79–83PubMedCrossRef
14.
Goiney RC, Connell DG, Nichols DM (1985) CT evaluation of tarsometatarsal fracture-dislocation injuries. AJR Am J Roentgenol 144(5):985–990PubMedCrossRef
15.
Goossens M, Stoop ND (1983) Lisfranc's Fracture-Dislocations: Etiology, Radiology, and Results of Treatment. Clin Orthop Relat Res 176:154–162
16.
Haapamaki V, Kiuru M, Koskinen S (2004) Lisfranc fracture-dislocation in patients with multiple trauma: diagnosis with multidetector computed tomography. Foot Ankle Int 25(9):614–619PubMedCrossRef
17.
Haapamaki VV, Kiuru MJ, Koskinen SK (2004) Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol 183(3):615–622PubMedCrossRef
18.
Hardcastle PH, Reschauer R, Kutscha-Lissberg E, Schoffmann W (1982) Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg 64(3):349–356CrossRef
19.
20.
Henning JA, Jones CB, Sietsema DL, Bohay DR, Anderson JG (2009) Open reduction internal fixation versus primary arthrodesis for lisfranc injuries: a prospective randomized study. Foot Ankle Int 30(10):913–922PubMedCrossRef
21.
Kosters C, Bockholt S, Muller C et al (2014) Comparing the outcomes between Chopart, Lisfranc and multiple metatarsal shaft fractures. Arch Orthop Trauma Surg 134(10):1397–1404PubMedCrossRef
22.
Krippendorff K (2008) Reliability. The international encyclopedia of communication. Wiley, Hoboken
23.
Kuo RS, Tejwani NC, Digiovanni CW et al (2000) Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg 82:1609–1618PubMedCrossRef
24.
Landis JR, Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33:159–174PubMedCrossRef
25.
Lau SC, Guest C, Hall M, Tacey M, Joseph S, Oppy A (2017) Do columns or sagittal displacement matter in the assessment and management of Lisfranc fracture dislocation? An alternate approach to classification of the Lisfranc injury. Injury 30:30
26.
Lu J, Ebraheim NA, Skie M, Porshinsky B, Yeasting RA (1997) Radiographic and computed tomographic evaluation of Lisfranc dislocation: a cadaver study. Foot Ankle Int 18(6):351–355PubMedCrossRef
27.
Mahmoud S, Hamad F, Riaz M, Ahmed G, Al Ateeq M, Ibrahim T (2015) Reliability of the Lisfranc injury radiological classification (Myerson-modified Hardcastle classification system). Int Orthop 39(11):2215–2218PubMedCrossRef
28.
Mallett S, Halligan S, Thompson M, Collins GS, Altman DG (2012) Interpreting diagnostic accuracy studies for patient care. BMJ 345:e3999PubMedCrossRef
29.
Mulier T, Reynders P, Dereymaeker G, Broos P (2002) Severe Lisfrancs injuries: primary arthrodesis or ORIF? Foot Ankle Int 23(10):902–905PubMedCrossRef
30.
Myerson MS, Fisher RT, Burgess AR, Kenzora JE (1986) Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle 6(5):225–242PubMedCrossRef
31.
Naguib S, Meyr AJ (2018) Reliability, surgeon preferences, and eye-tracking assessment of the stress examination of the tarsometatarsal (Lisfranc) joint complex. J Foot Ankle Surg 58:93–96PubMedCrossRef
32.
Norfray JF, Geline RA, Steinberg RI, Galinski AW, Gilula L (1981) Subtleties of Lisfranc fracture-dislocations. Am J Roentgenol 137(6):1151–1156CrossRef
33.
Nunley JA, Vertullo CJ (2002) Classification, investigation, and management of midfoot sprains. Am J Sports Med 30(6):871–878PubMedCrossRef
34.
Ponkilainen VT, Laine H-J, Mäenpää HM, Mattila VM, Haapasalo HH (2018) Incidence and characteristics of midfoot injuries. Foot Ankle Int 40(1):105–112PubMedCrossRef
35.
Porter DA, Barnes AF, Rund A, Walrod MT (2018) Injury pattern in ligamentous Lisfranc injuries in competitive athletes. Foot Ankle Int 40(2):185–194PubMedCrossRef
36.
Potter HG, Deland JT, Gusmer PB, Carson E, Warren RF (1998) Magnetic resonance imaging of the Lisfranc ligament of the foot. Foot Ankle Int 19(7):438–446PubMedCrossRef
37.
Preidler KW, Brossmann J, Daenen B, Goodwin D, Schweitzer M, Resnick D (1996) MR imaging of the tarsometatarsal joint: analysis of injuries in 11 patients. Am J Roentgenol 167(5):1217–1222CrossRef
38.
Preidler KW, Peicha G, Lajtai G et al (1999) Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. Am J Roentgenol 173(6):1673–1677CrossRef
39.
Quenu EKG (1909) Etude sur les luxations du metatarse (Luxations metatarso-tarsiennes). Du diastasis entre le 1er et le 2e metatarsien. Rev Chir 39:1–72
40.
Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC (2009) Prediction of midfoot instability in the subtle Lisfranc injury: comparison of magnetic resonance imaging with intraoperative findings. JBJS 91(4):892–899CrossRef
41.
Rajapakse B, Edwards A, Hong T (2006) A single surgeon's experience of treatment of Lisfranc joint injuries. Injury 37(9):914–921PubMedCrossRef
42.
Rankine JJ, Nicholas CM, Wells G, Barron DA (2012) The diagnostic accuracy of radiographs in Lisfranc injury and the potential value of a craniocaudal projection. Am J Roentgenol 198(4):W365–W369CrossRef
43.
Renninger CH, Cochran G, Tompane T, Bellamy J, Kuhn K (2017) Injury characteristics of low-energy Lisfranc injuries compared with high-energy injuries. Foot Ankle Int 38(9):964–969PubMedCrossRef
44.
Ross G, Cronin R, Hauzenblas J, Juliano P (1996) Plantar ecchymosis sign: a clinical aid to diagnosis of occult Lisfranc tarsometatarsal injuries. J Orthop Trauma 10(2):119–122PubMedCrossRef
45.
Schepers T, Rammelt S (2018) Classifying the Lisfranc injury: Literature overview and a new classification. Fuß Sprunggelenk 16:151–159CrossRef
46.
Seo DK, Lee HS, Lee KW, Lee SK, Kim SB (2017) Nonweightbearing radiographs in patients with a subtle Lisfranc injury. Foot Ankle Int 38(10):1120–1125PubMedCrossRef
47.
Shapiro MS, Wascher DC, Finerman GA (1994) Rupture of Lisfranc's ligament in athletes. Am J Sports Med 22(5):687–691PubMedCrossRef
48.
Sherief TI, Mucci B, Greiss M (2007) Lisfranc injury: how frequently does it get missed? And how can we improve? Injury 38(7):856–860PubMedCrossRef
49.
Sivakumar BS, An VV, Oitment C, Myerson M (2018) Subtle Lisfranc injuries: a topical review and modification of the classification system. Orthopedics 41(2):e168–e175PubMedCrossRef
50.
Sripanich Y, Weinberg MW, Krähenbühl N et al (2019) Imaging in Lisfranc injury: a systematic literature review. Skelet Radiol 49:1–23
51.
52.
Talarico RH, Hamilton GA, Ford LA, Rush SM (2006) Fracture dislocations of the tarsometatarsal joints: analysis of interrater reliability in using the modified Hardcastle classification system. J Foot Ankle Surg 45(5):300–303PubMedCrossRef
53.
Vuori JP, Aro HT (1993) Lisfranc joint injuries: trauma mechanisms and associated injuries. J Trauma-Injury Inf Crit Care 35(1):40–45CrossRef
Metadata
Title
Inter- and intraobserver reliability of non-weight-bearing foot radiographs compared with CT in Lisfranc injuries
Publication date
01-10-2020
Published in
Archives of Orthopaedic and Trauma Surgery / Issue 10/2020
Print ISSN: 0936-8051
Electronic ISSN: 1434-3916
DOI
https://doi.org/10.1007/s00402-020-03391-w

Other articles of this Issue 10/2020

Archives of Orthopaedic and Trauma Surgery 10/2020 Go to the issue

Trauma Surgery

An intuitive and simple technique for accurate insertion point selection and precise Poller (blocking) screw insertion

Arthroscopy and Sports Medicine

Quadriceps tendon vs. patellar tendon autograft for ACL reconstruction using a hardware-free press-fit fixation technique: comparable stability, function and return-to-sport level but less donor site morbidity in athletes after 10 years

Arthroscopy and Sports Medicine

Predictive factors for failure of anterior cruciate ligament reconstruction via the trans-tibial technique

Handsurgery

Digital avulsion injuries: epidemiology and factors influencing finger preservation

Knee Arthroplasty

Validation of the Oxford Knee Score and Lower Extremity Functional Score questionnaires for use in Slovenia

Orthopaedic Surgery

Double-plate compound osteosynthesis for pathological fractures of the proximal femur: high survivorship and low complication rate