The Accuracy of 3D Measurements in Weightbearing Computed Tomography to Diagnose Lisfranc Instability
Authors: Flaherty Alexandra F. , Ranganathan Noopur , Waryasz Gregory , Guss Daniel , Ashkani-Esfahani Soheil , DiGiovanni Christopher W. , Bejarano-Pineda Lorena 
Published: December 2023

Category: Midfoot/Forefoot; Other Introduction/Purpose: Up to one-third of Lisfranc injuries are missed on initial evaluation, resulting in significant morbidity. Prompt diagnosis of Lisfranc injuries is, therefore, critical in optimizing outcomes, and yet there remains a lack of consensus on diagnostic criteria to identify Lisfranc instability using anatomic measurements. Prior studies have underscored the utility of weight-bearing computed tomography (WBCT) in diagnosing Lisfranc instability, which allows for bilateral three-dimensional (3D) evaluation under physiologic load. The aim of this study was to quantify appropriate cutoff values using 3D anatomic measurements of Lisfranc instability under physiologic load and as compared to the uninjured extremity. Methods: A total of 234 adult patients with bilateral WBCT scans of the foot were included: 43 patients with Lisfranc instability & 191 patients without a history of midfoot injuries. Lisfranc instability was confirmed intraoperatively or by clinical evaluation by the surgeon. Patients with prior midfoot surgery, Charcot arthropathy, severe midfoot arthropathy, or significantly displaced fracture of the cuneiforms or 1st, 2nd, or 3rd metatarsal bases were excluded. Lisfranc joint measurements were conducted bilaterally, including C1-M2 diastasis, C1-M2 area and 3D WBCT volume. Patient demographics were collected. Descriptive statistics were calculated for quantitative variables. Percent difference as compared to the contralateral side was calculated for volume, area, and diastasis. Mann Whitney U tests were utilized to determine differences in measurements between patients in the Lisfranc cohort and patients in the uninjured cohort (p-value < 0.05). Diagnostic cutoffs for Lisfranc instability were determined with minimum distance to the corner analysis on ROC curves. Results: The distribution of patients with Lisfranc instability was 58% female with an average age of 38.5±17.6 years. Of the Lisfranc injuries, 36% were purely ligamentous, 18% demonstrated an avulsion injury, and 43% involved a metatarsal base fracture. In the Lisfranc cohort, the median percent difference between injured and uninjured feet was 28.2% (IQR: 20.9%) for volume, 36.3% (IQR: 31.1%) for C1-M2 area, and 40.0% (IQR: 23.3%) for C1-M2 diastasis. Mann-Whitney testing was significant for percent difference between left and right feet for Lisfranc patients versus patients with an uninjured midfoot (p < 0.001). The area under the curve and associated diagnostic cutoffs for Lisfranc instability, were 0.81 and 18% for volume, 0.84 and 20% for area, and 0.91 and 28% for diastasis (Figure 1). Conclusion: Diastasis (1D), area (2D), and volume (3D) measurements are effective measurements to diagnose Lisfranc instability on WBCT. With current diagnostic algorithms, however, 1D measurements afford superior diagnostic sensitivity as compared to 2D and 3D measurements when using WBCT, suggesting Lisfranc instability may be best appreciated in the axial plane. Additional studies are necessary to expand the sample population to assess for corroboration with the current results, especially for subtle Lisfranc instability.