Normal Variation of the Lisfranc Joint: Tridimensional Analysis using Weight-Bearing Computed Tomography Imaging
Authors: Ranganathan Noopur , Flaherty Alexandra F. , DiGiovanni Christopher W. , Ashkani-Esfahani Soheil , Bejarano-Pineda Lorena 
Published: December 2023

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: Untreated Lisfranc injuries can lead to chronic pain, midfoot arthritis, and functional disability 1,2,5. Approximately 20% of Lisfranc injuries are misdiagnosed or completely missed on initial evaluation, which can be attributed to a lack of parameters of what is within normal limits for subjects without injury in the Lisfranc complex3,4. The purpose of this study is to identify anatomic variations of unidimensional, bidimensional, and tridimensional (1D, 2D, 3D) measurements of the Lisfranc complex of normal individuals using weight-bearing computed tomography (WBCT) imaging. Our hypothesis is that there is some variation among individuals with a difference between right and left of the same individual of less than 10%. Methods: A total of 191 subjects with bilateral WBCT scans of the foot were collected from three tertiary medical centers from 2019-2022. Exclusion criteria included: history of Lisfranc injury, first to fourth metatarsal base fractures, Charcot arthropathy, midfoot arthritis, cuneiform fractures, and forefoot surgery proximal to the metatarsal neck region. The following Lisfranc joint measurements were collected6 bilaterally: joint volume (3D), area of the joint on a consistent axial slice (2D), and distance between the second metatarsal and medial cuneiform (1D). Foot alignment was assessed using lateral talar-first metatarsal angle (Meary’s Angle). Patient demographics (age, sex, weight, height, BMI) were also collected. Descriptive statistics were calculated for quantitative variables. Percent difference was used to assess volume, area, and distance variation between sides.7 Correlation between demographic data and Lisfranc measurements was assessed using Pearson Correlation tests. A T-test was used for categorical variables. A p-value < 0.05 was considered statistically significant. Results: The cohort included 61% female and 39% male with an average age of 45.2±17.3 years. The mean volume, area, and distance measurements of the Lisfranc joint for both left and right sides are shown in Figure 1. Overall, the mean percent difference between left and right sides were 11.9%, 14.9% and 13.9% for volume, area and diastasis, respectively (Figure 1). No association was found between age, BMI, or weight and the volume, area or distance measurements. A correlation (r=0.48, p= < 0.001) was found between height and left Lisfranc joint volume, but no other measurements. Significant difference between sex in volume (p < 0.001) and area (p < 0.001) measurements were found. Foot alignment did not have a correlation with a variation of the Lisfranc complex measurements. Conclusion: This study provides an objective characterizing of the anatomic variations of the Lisfranc joint amongst healthy individuals. Differences in the measurements and the large standard deviation in absolute measurements of volume, area, and distance suggests that percent difference with the contralateral side may be a better metric to use to diagnose Lisfranc instability. Our results showed that the difference between bilateral sides in a patient is less than 15% for volume, area, and diastasis. The results of this study can set the foundation for future studies to determine the cut-off value for the diagnosis of Lisfranc instability using WBCT imaging.