Rev. bras. ortop. vol.49 número4

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w w w . r b o . o r g . b r

Update

Article

Turco’s

injury:

diagnosis

and

treatment

夽

,

夽夽

Ana

Paula

Simões

da

Silva

∗

_,

_Leandro

_Girardi

_Shimba,

Luiz

Henrique

Boraschi

Vieira

Ribas,

Alexandre

Simmonds

de

Almeida,

Vinicius

Naves,

Aires

Duarte

Júnior

FaculdadedeCiênciasMédicasdaSantaCasadeSãoPaulo,PavilhãoFernandinhoSimonsen,SãoPaulo,SP,Brazil

a

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t

i

c

l

e

i

n

f

o

Articlehistory:

Received2May2013

Accepted16July2013

Availableonline14May2014

Keywords:

Tarsaljoints/injuries

Metatarsalbones

Bonefractures

Dislocations

a

b

s

t

r

a

c

t

TheaimofthisstudywastoalertdoctorstotheexistenceofTurco’sinjuryanddiscusthe

existingtreatmentsthathavebeendescribedintheworldwideliterature.Abibliographic

surveyofLisfranc’sinjuryandTurco’sinjurycoveringfrom1985to2013wasconductedin

theSciELOandPubMeddatabases.Amongthe193articles,thoserelatingtobone-ligament

injuriesoftheLisfrancjointandhigh-energytraumawereexcluded,aswerethecasereports.

Thepatientsselectedwereprofessionaloramateurathleteswhosolelypresentedaligament

injurytotheLisfrancjoint(Turco’sinjury),whichwasdiagnosedfromthehistory,physical

examination,radiographsandmagneticresonanceimages.Non-athleticpatientsandthose

withassociatedboneinjurieswereexcluded(10).Accordingtotheinjuryclassification,the

patientsweretreatedbymeansofeitheranopenoraclosedprocedureandthenastandard

rehabilitationprotocol.Outofthe10patients,fiveunderwentconservativetreatmentand

fiveunderwentsurgicaltreatmentusingdifferenttechniquesandsynthesismaterials.We

obtainedtwopoorresults,onesatisfactory,fivegoodandtwoexcellent.Weconcludethat

thecorrectdiagnosishasadirectinfluenceonthetreatmentandonthefinalresultobtained,

andthatlackofknowledgeofthisinjuryisthemainfactorresponsibleforunderdiagnosing

Turco’sinjury.Thereisaneedforrandomizedprospectivestudiescomparingthetypesof

synthesisandevolutionoftreatedcases,inordertodefinethebesttreatmentforthisinjury.

Ltda.Allrightsreserved.

Lesão

de

Turco:

diagnóstico

e

tratamento

Palavras-chave:

Articulac¸õestarsianas/lesões

Ossosdometatarso

Fraturasósseas

Luxac¸ões

r

e

s

u

m

o

EstetrabalhotemporobjetivosalertarosmédicossobreaexistênciadalesãodeTurcoe

discorrersobreostratamentosexistentesdescritosnaliteraturamundial.Foifeito

levan-tamentobibliográficodalesãodeLisfrancedalesãodeTurcode1985a2013nasbases

dedadosScieloePubmed.Dos193artigos,foramexcluídososcomlesão

osteoligamen-tardaarticulac¸ãodeLisfranc,osportraumasdealtaenergia,osrelatosdecaso.Foram

夽_Please_cite_this_article_as:_da_Silva_APS,_Shimba_LG,_Ribas_LHBV,_de_Almeida_AS,_Naves_V,_Duarte_Júnior_A._Turco’s_injury:_diagnosis_and

treatment.RevBrasOrtop.2014;49:321–327.

夽夽

WorkperformedintheSportsTraumatologyGroup,DepartmentofOrthopedicsandTraumatology,SchoolofMedicalSciences,Santa

CasadeSãoPaulo,FernandinhoSimonsenWing.

∗ _{Corresponding}_author_.

E-mail:apaulass@gmail.com(A.P.S.daSilva).

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selecionadospacientesatletasprofissionaisouamadores,comlesãoligamentarexclusiva

daarticulac¸ãodeLisfranc(lesãodeTurco),aqualfoidiagnosticadapelahistória,peloexame

físico,pelasradiografiasepelaressonânciamagnética.Comofatoresdeexclusão,pacientes

nãoatletasecomlesõesósseasassociadas(10).Deacordocomaclassificac¸ãodalesão,os

pacientesforamtratadoscruentaouincruentamenteesubmetidosaumprotocolo-padrão

dereabilitac¸ão.Dos10pacientes,cincoforamsubmetidosatratamentoconservadorecinco

atratamentocirúrgico,pordiferentestécnicasemateriaisdesíntese.Obtiveram-sedois

resultadosruins,umsatisfatório,cincobonsedoisexcelentes.Concluímosqueo

diag-nósticocorretoinfluenciadiretamentenotratamentoenoresultadofinalobtidoequeo

desconhecimentodalesãoéoprincipalresponsávelpelosubdiagnósticodalesãodeTurco.

Hánecessidadedeestudosprospectivosrandomizadosquecomparemostiposdesíntese

eaevoluc¸ãodoscasostratadosparaumadefinic¸ãodomelhortratamentoparatallesão.

EditoraLtda.Todososdireitosreservados.

Introduction

TheLisfrancortarsometatarsaljointisthusnamedinhomage

totheFrenchphysicianJacquesLisfranc,who wasthefirst

todescribeanamputation throughthis joint.1–4 _This

com-plexis formedbybone elements (base ofthe metatarsals,

cuneiformsandcuboid)andligamentsthatgivestructureand

supporttothetransverse archofthemidfoot.Betweenthe

medialcuneiformandthesecondmetatarsal,thereisastrong

obliqueligamentcalledtheLisfrancligament.This,in

asso-ciation with the effect of the most proximalfitting ofthe

secondmetatarsal,formsthemainstabilizerofthisjoint.1,3,5–8

Thecomplexanatomyofbonesandligamentsinthisregion,

inassociationwiththemultipleinjurypatterns and

mech-anisms,makesradiographic interpretation and diagnosis a

challenge,particularlyinattendingemergencycases.9

Dislocated fractures of the Lisfranc joint are unusual

injuries of the foot and occur at a rate of 1:55,000 to

60,000 per year, which corresponds to 0.1% to 0.9% of all

fractures.Approximatelyonethirdoftheseinjuriesgo

undi-agnosed,whichmayleadtochronicpaininthefootaffected,

osteoarthrosis and deformities.1,3,10–13 _Among _the _various

injurymechanismsthathavebeendescribed,thecommonest

isplantarflexion over the metatarsals,inassociation with

rotationalstress.9_In_this_manner,_it_is_important_for

physi-cianstobecomefamiliar withthe typesofpresentationof

Lisfranc dislocated fractures, and specifically the one

dis-cussedinthisstudy,whichbearsthenameofTurco’sinjury,

giventhatearlydiagnosisandinterventionareessentialfor

betterprognosis.14,15 _Turco’s_injury_is_one_in_which_there_is

alow-energytraumamechanismthatonlycausesligament

tears,withorwithoutdislocationofthisjoint,anditoccurs

especiallyamongathletes.9

Thisinjuryisthereforecharacterizedbyanopeningofup

to5mmintheintermetatarsalspaceofthefirstandsecond

metatarsals,and itmay range inseverity, accordingtothe

classificationofNunleyandVertullo,fromstageItoIV.16

Anatomyandbiomechanics

Understandingtheanatomyofthetarsometatarsalcomplex

isessential forit tobe possible toevaluate, diagnose and

treatinjuries tothis joint.Thestability of this complex is

achieved through bone architecture and ligament support.

The first,second and thirdmetatarsals articulate with the

medial,intermediateandlateralcuneiforms,inthisorder,and

the fourthandfifthmetatarsals articulatewiththecuboid.

The second metatarsal notonlylies between the first and

third metatarsals, but also has a greater contact surface

withthebonesthatsurroundit,giventhattheintermediate

cuneiformislocatedmoreproximallythanthemedialand

lat-eralcuneiforms.Thus,ithasalock-and-boltfitthatincreases

thestability.17,18

Inadditiontothestructuredboneframework,thereisa

ligament support. Thebones ofthe metatarsus are joined

togetherbymeansofthedorsalandplantarintermetatarsal

ligaments, asare alsothe cuneiforms and the cuboid, but

thereisnoligamentthatjoinsthebaseofthefirstmetatarsal

to the second metatarsal. There is also a variable

net-work of longitudinal and oblique ligaments that secures

the last four metatarsals tothe cuneiformsand cuboid on

the plantar and dorsal sides, along with two longitudinal

ligaments that anchor the first metatarsal in the medial

cuneiform.17,18

Thelargestandstrongestligamentofthetarsometatarsal

complex isthe so-calledLisfranc ligament. Itsorigin isin

thelateralsurfaceofthemedialcuneiformanditisinserted

intothemedialfaceofthebaseofthesecondmetatarsal17,18

(Fig.1).

Physiopathology

Lisfrancinjuriescanbecausedbydirectorindirect

mecha-nisms.Direct traumatothe dorsumofthefootisrare and

maybecomplicatedthroughcontamination,vascular

impair-mentandcompartmentalsyndrome.Injuriesthroughindirect

mechanismsareresponsibleformostcasesandresultboth

fromrotationalforcesappliedtotheforefootwiththe

hind-foot fixed and from axial loads on a fixed foot in plantar

flexion.14

Thecommonestcause ofindirect traumathat hasbeen

described inthe literature iscar accidents, which account

forapproximately40%to45%oftheinjuries.17_Other_causes

thathavebeendescribedincludeactsoffallingfromaheight,

accidentswithhorses,motorcycleaccidentsand injuriesin

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Fig.1–Representationoftheboneanatomyofthemidfoot andhindfoot,inwhich“lock-and-bolt”fittingofthesecond metatarsalwiththecuneiformswasobserved.TheLisfranc ligamentishighlightedandthemetatarsals(ItoV)are identified.

Diagnosis

Well-conductedclinical history-taking and physical

exami-nationarefundamentalforthediagnosis.Patientsgenerally

reveal the trauma mechanism and report having pain in

themidfoot,varyinggreatlyinintensity.Theyaregenerally

asymptomaticwhenwalking,butpresentpainwhenrunning,

jumpingandmakingothersportsmovements.Itisimportant

tolocate thepainfulpoints.Painonpalpationbetweenthe

baseofthefirstandthesecond metatarsalisanimportant

finding,evenwithoutinjuriesinvolvingdiastasisofthe

inter-metatarsal space.12,15–17 _Provocative _tests_may _also_be_very

helpful.Thetwotestsmostfrequentlyusedarelateral

com-pressiontestandtheaxialstabilitytestbetweenthefirstand

secondmetatarsals,whicharepositivewhentheyreproduce

paininthemidfoot.Shapiroetal.19_concluded_that_these_two

testsarepositivewhenthereisruptureoftheLisfranc

liga-ment.Thereisalsoaspecifictestfortarsometatarsalinjuries,

which consistsofpassive pronation withabduction ofthe

forefoot,with the hindfoot fixed. Thismaneuver produces

painatthesiteoftheinjuredligament.

Well-producedradiographsare alsofundamentalforthe

diagnosis. Anteroposterior (AP), lateral (L) and oblique (O)

viewsshouldbeproduced,withloadingifpossible.A

compar-isonwithradiographsonthecontralateralfootmaybeuseful

fordetectingsubtleinjuries.IntheAPview,themedialfaceof

theintermediatecuneiformshouldbealignedwiththemedial

faceofthesecondmetatarsal.Intheobliqueview,the

parame-terfornormalityisthemedialfaceofthecuboid,whichshould

bealignedwiththemedialfaceofthefourthmetatarsal.In

profileview,thepresenceofanteriororposteriordislocation

orsubluxationofthetarsometatarsaljointscanbeobserved.

Ifthereisanydoubt,APandlateral-viewradiographscanalso

beobtainedwithloading,whichmayhelptoshowdiastasis

betweenthefirstandsecondmetatarsalsinAPview.Inlateral

viewwithloading,adroppedplantararchordorsal

subluxa-tioncanbeseen.11,12,14–17

Classification

TheclassificationusedforTurco’sinjuryistheoneproposed

byNunleyandVertullo,whichisspecificformidfootinjuries

inathletes.Thisclassificationdividestheinjuriesintothree

stages.InsprainstageIoftheLisfrancligament,thereisno

diastasisorlossoftheplantararch.InsprainstageII,there

isadiastasisof2mmto5mmduetofailureoftheLisfranc

ligament,butthereisnolossoftheplantararch.InstageIII,

thereisadiastasisbetweenthefirstandsecondmetatarsals

andlossoftheplantararch16₍_Fig.₂_).

Materials

and

methods

ScientificarticlesthatspecificallydiscussedLisfranc’sinjury

andTurco’sinjurybetween1985and2012weresurveyedinthe

ScieloandPubmeddatabases,usingthefollowingdescriptors:

“Lisfrancjoint”,“tarsometatarsaljoint”,“injuries”,“fracture”,

“dislocation”,“treatment”and“outcome”.Onehundredand

ninety-threearticleswerefound,andarticlesdescribingthe

followingwereexcluded: boneandligamentinjuriesofthe

Lisfrancjoint;injuriesduetohigh-energytrauma;andcase

reports.Theinformationwascomparedwithcasessurveyed

inatypicalteachinghospitalinalargecitybetween2006and

2011regardingthetreatmentused,follow-up,postoperative

evaluationandreturntopre-injuryactivities.Thedatawere

organizedaccordingtosportsactivity,age,sideaffected,

clas-sification,treatmentandfollow-up(Table1).

Thepatientsselectedforinclusioninthisstudywere

pro-fessionaloramateurathleteswithligamentinjuriessolelyin

theLisfrancjoint(Turco’sinjury),whichwerediagnosedfrom

thehistory,physicalexamination,radiographsandmagnetic

resonanceimaging.Patientswhowerenotathletesandwho

presentedassociatedbonelesionswereexcluded.Agroupof

10patientswasthusformed:sixmen(60%)andfourwomen

(40%),withameanageof35years(20to61).Theleftsidewas

affectedineightcases(80%)andtherightsideintwocases

(20%).TheassessmentsusingtheclassificationofNunleyand

Vertullo16_were:_four_cases_of_type_I_(40%),_four_of_type_II_(40%)

andtwooftypeIII(20%).Themeanfollow-upwas44.9months

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Lisfranc ligament sprain

No diastasis

Ruptured lisfranc ligament _2-5mm

diastasis

Diastasis & loss of longitudinal arch

height

Stage I Stage II

Stage III

Diastasis, no arch height loss

2-5mm diastasis Ruptured lisfranc

ligament

Fig.2–NunleyandVertulloclassification.16

Table1–Distributionof10patientswithTurco’sinjury,organizedaccordingtogender,sportsactivity,sideaffected, classification16_and_treatment.

Case Gender Age Date Sportsactivity Sideaffected Classification Treatment

1 Male 20 2007 Baseball Right II Surgical

2 Male 31 2010 Soccer Left II Surgical

3 Male 27 2007 Baseball Left III Surgical

4 Male 24 2011 Recreationalsoccer Left I Conservative

5 Male 44 2011 Soccer Left I Conservative

6 Male 28 2006 Soccer Left III Surgical

7 Female 61 2009 Walking Left I Conservative

8 Female 31 2009 Walking Left II Conservative

9 Female 61 2007 Golf Left II Surgical

10 Female 23 2008 Artisticgymnastics Right I Conservative

The patients were treated conservatively or surgically, accordingtotheclassificationoftheinjury.

All the patients underwent our group’s standard reha-bilitation protocol,whichconsisted offourto sixweeksof immobilizationusingabrace,withoutloading,withanalgesic physiotherapyandtrainingofsportsmovements.

Toanalyzetheresults,weusedsubjectiveassessmentthat tookintoaccountpainandsportspracticeperformance,which was considered to be poor, satisfactory, good or excellent. Theresults were considered tobe poor if the patient pre-sented painand didnotreturn tothe sport;satisfactoryif thepatientcontinuedtopresentpainbutreturnedtosports practicebelowthepre-injuryperformancelevel;goodifthe patientpresentedpain butreturned tosports practiceata levelsimilartobeforetheinjury;andexcellentifthepatient didnotpresentpainandreturnedtothesportatthesame levelasbeforetheinjury.

Atthefollow-upassessments,radiographswereproduced inanteroposterior,lateralandobliqueviews,withloading,in ordertoevaluatetheevolution.

Result

After careful individualized analysis on each medical file (each patient), the cases were stratified based on the type oftreatment,postoperativecomplications,results,lengthof follow-upandradiographicsignsofarthrosis.

The patients with type I injuries (4, 5, 7 and 10) were treatedconservativelyinaccordancewithourstandard pro-tocol:patients5and7evolvedwithgoodresultsandpatients 4and10withexcellentresults.

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Table2–Distributionof10patientswithTurco’sinjury,accordingtothetypeoftreatment,rehabilitation,complications presentedandreturntosportsactivity.

Case Typeoftreatment Postoperativecomplications Result Follow-up(months) Arthrosis

1 ORIFwith2parallelSFS Superficialskininfection anddehiscenceofsuture

Good 61months No

2 ORIFwith1obliqueSFS Superficialskininfection andnon-anatomical reduction

Poor 34months Yes

3 ORIFwith2divergentSFS and1Kirschnerwire

Absent Good 59months No

4 Conservative Absent Excellent 18months No

5 Conservative Absent Good 17months No

6 ORIFwith2parallelSFS Absent Satisfactory 76months Yes

7 Conservative Absent Good 36months Yes

8 Conservative Absent Poor 37months No

9 ORIFwith2parallelSFS Absent Good 60months Yes

10 Conservative Absent Excellent 51months No

ORIF,openreductionandinternalfixation;SFS,small-fragmentscrews(3.5mm).

openreductionandinternalfixation(ORIF),usingtwoparallel small-fragmentscrews(3.5mm),whichinonecasewentfrom themedialcuneiformtothebaseofthesecondmetatarsaland intheothercasefromthemedialcuneiformtothe intermedi-atecuneiform.Duringthefollow-up,bothofthempresented goodresults,althoughpatient1evolvedwithdehiscenceof thesutureandsuperficial skininfection,without arthrosis, whilepatient9hadnocomplicationsoftheoperativewound but showed radiographic signs of arthrosis. Patient 2 was treated with ORIF, using an oblique small-fragment screw goingfromthemedialcuneiformtothebaseofthesecond metatarsal.Thispatientevolvedwithsuperficialskin infec-tion duringthe postoperative periodand presenteda poor resultduringthefollow-up,whichweattributedtothe non-anatomicalreduction obtainedinthe surgery. Thispatient evolvedwitharthrosis.Patient8,whoalsohadatypeIIinjury, wastreatedinaclosedmanner,becauseoflatediagnosisand radiographicevidenceofmidfootankylosis,andpresenteda poorresult.

Thepatients with typeIII injuries (3 and 6) underwent surgicaltreatment.Patient3underwentORIFusingtwo diver-gentsmall-fragment spongy screwswith partialthreading: onefrom the medialcuneiform tothe base ofthe second metatarsalandtheotherfromthemedialcuneiformtothe intermediatecuneiform,inassociationwithaKirschnerwire fromthesecond metatarsaltotheintermediatecuneiform. During the evolution, this patientpresented agood result, without arthrosis. This patient underwent removal of the Kirschnerwireaftersixweeks.Patient6wastreatedwithORIF usingparallelscrews,withsatisfactoryevolutionandarthrosis (Table2).

Discussion

Accordingtotheliterature,morethan20%ofdislocated

Lis-francfracturesarenotdiagnosedintheinitialevaluation,3,4

whichmakessuspicionandearlydiagnosisprerequisitesfor

correctmanagementofthisinjury.Toavoidsequelaeoverthe

longterm,andfunctionalimpotenceofthisjoint,the

consen-susisthatanatomicalreductionandjointstabilizationshould

beperformed,sothatthefollow-upwillbesatisfactoryand

therecoveryadequate.20–24 _Lisfranc_injuries_generally_result

fromhigh-energytrauma.3_Car_accidents_are_the_main_cause

oftheseinjuries.Inoursample,thecommonesttrauma

mech-anismwaslow-energy.Theprincipalduringsportspracticeis

plantarflexionoverthemetatarsals,inassociationwith

rota-tionalstress,inaccordancewithwhatwasdescribedinTurco’s

originalarticle.15

Thediagnosisisobtainedthroughdetailedphysical

exami-nation,whichshowsuppatientsforwhomitisdifficultoreven

impossibletobearweightontheaffectedlimb,withpainon

palpationintheregionofthejointbetweenthefirstand

sec-ondmetatarsals,andpossiblyalsoedemaandlocalsweating.

Itisveryimportanttoperformradiographswithloadingon

theaffectedfoot,inthefrontal,lateralandobliquepositions.

Incasesofdoubt,magneticresonanceimagingisindicatedfor

thediagnosis.

TheclassificationdescribedbyNunleyandVertullo16_was

used to interpret and classify the injuries, and this also

guided the treatment.There is noconsensusin the

litera-tureregardingthetreatment:openorclosedreductionusing

wiresorscrews;thepositioningofthescrews;andwhether

arthrodesisisindicated.Inoursample,noneofthepatients

underwent arthrodesis.Arthrodesis isa predictable

conse-quenceofinjuriesthatare notadequatelyreduced,withor

without associatedfailureofthesynthesis,orundiagnosed

injuries that evolve with symptomatic arthrosis. However,

therewasonecase(patient8)forwhomthediagnosiswasnot

madeattheinitialattendance,whichwasatanotherservice.

Thispatientwas admittedtoourservicewithtwomonths

ofevolution ofthe injury, and conservative treatment was

chosen.Thepatientevolvedwitharthrosisandankylosis,but

withoutsymptomsthatwouldjustifyarthrodesis.

Aspublishedinrecentstudies,anatomicalreductionand

internalfixationaretheessentialfactorsforagood

therapeu-ticresultsincasesofinjuriesclassifiedastypesIIandIIIby

NunleyandVertullo.Thisisconcordantwithourresults,as

showninpatient2,inwhomanatomicalreductionwasnot

achieved, withconsequent evolutionto apoorresult.7,25–31

ConservativetreatmentwasonlyindicatedforgradeIinjuries,

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ofthesofttissues,andalsobecauseofthetendencytoward

initialdisplacement.22

Grade II and III injuries can be dealt with using

sev-eral techniques and approaches, which vary according to

thesurgeon’sexperienceandpreference.Thesemayinclude

closed reductionand percutaneous fixation using wiresor

screws,32 _open _reduction_and _internal _fixation _using _these

samematerials17,20,24,33_and_even_primary_arthrodesis.30

In 2003, Perugia et al.34 _treated _this _type _of _injury _by

meansofclosedreductionandinternalfixationusing

percu-taneous4mmspongyscrews,in42patients:12withpurely

ligament injuries and 30 with bone and ligament injuries,

with follow-up of close to 58 months. The results were

evaluatedusingtheAOFASmidfootfunctionalscorewitha

meanof81points.Intheirstudy,thetreatmentsandresults

obtainedwere notdifferentiated betweenthe patientswith

solelyligamentinjuries(Turco’sinjury)andthosewith

bone-ligamentinjuries(Lisfrancfracture-dislocation).Furthermore,

the authors did not give any informationregarding

evolu-tionoftheircasestoarthrosis,thereturntoworkorresidual

pain.

Perezetal.,24_Rammelt_et_al.25_and_Tan_et_al.26_used_open

reductionand internalfixationwithKirschnerwires(2.5 to

3.5mm), through one or two access routes. In their study,

amongallthecomplicationspossible(infection,lossof

reduc-tion or skin necrosis),Perez et al.24 _presented_one_case _of

infectionandthreewithskinnecrosis,withafollow-upof76

months.Rammeltetal.25_showed_one_case_with_skin

necro-sisandonewithinfection.Overa36-monthfollow-up,Tan

etal.26_found₁₀_cases_of_arthrosis_of_the_{tarsometatarsal}_joint,

butall thesepatientsreturned towork.Elevenout oftheir

12patientspresentedcompleteorpartialpainrelief.Noneof

theseauthorsreportedanylossofreductionoverthecourse

oftheirpatients’follow-ups,andthesynthesismaterialswere

removedeightweeksaftertheoperation.Wehadonecasein

whichmixedsynthesiswasused(screwandwire),inwhich

thewirewasremovedsixweeksaftertheoperation.There

werenocomplicationsandweobtainedagoodresult.

Thegreatmajorityoftheauthors7,25,27–30,33,34 _used_open

reductionandinternalfixationusingsmall-fragmentscrews.

OnlyMulieretal.31_performed_treatments_with_{large-fragment}

screws(4.5mm).Intheirstudy,conductedon16patientswith

30monthsoffollow-up,thesynthesismaterialwasremoved

after12 weeks,afterevidenceofboneconsolidationand/or

ligamenthealingwasseen.Theresultsthattheypresented

included:twopatientswithsympathetic-reflexdystrophy,15

withevolutiontoearlyarthrosisofthisjointandtwocases

that,becauseoftheseverityoftheinjury,underwentprimary

arthrodesis.Inagreementwiththeliterature,weusedORIF

withsmall-fragmentscrews.

Among the studies in which the patients with

bone-ligament injuries to the Lisfranc joint underwent open

reductionandinternalfixationusingtwoscrews,Arntzetal.7

hadthefollowingresultsamong34patients:20evolvedwith

arthrosis,without the need forarthrodesis, 21 returned to

workand29hadcompleteorpartialpainrelief.Kuoetal.28

foundthat12oftheir48patientshadproblemswiththe

fix-ation,consistingoflooseningofthesynthesismaterialand

lossofthereduction.Thesepatientsevolvedwitharthrosis,

butonlysixofthemrequiredarthrodesis.

LyandCoetzee29_performed_open_reduction_and_internal

fixationwithtwoscrewsontheirpatientswithpurely

liga-mentinjuries(20cases).Theyfoundsynthesisfailurein16

cases and evolutionto arthrosis in15 cases.Of these,five

patientsunderwentreoperationwitharthrodesis.Amongthe

20patientstreated,onlysixreturnedtowork.Amongour10

casesofpurelyligamentinjury,fiveweretreatedsurgicallyand

fourofthemunderwentORIFwithtwoscrews.Ofthese,one

evolvedwithinfectionanddehiscenceofthesuture(patient1),

butpresentedagoodresultwithoutarthrosis.Twopresented

goodresultsinwhichoneevolvedwithasymptomatic

arthro-sis(patient9)andtheotherwithoutarthrosis(patient3).The

lastofthesecases(patient6)presentedasatisfactoryresult

withasymptomaticarthrosis.

WedidnotusetheAOFASscoreinourevaluationbecause

thisisnotasatisfactoryevaluationmethodamongathletes.

For thisreason,wesuggestthatthereshouldbean

evalua-tion described inthe materialsandmethods thatstratifies

theresultsintopoor,satisfactory,goodandexcellent,witha

clinicalcorrelation.

Conclusion

Correctdiagnosis directlyinfluencesthetreatmentand the

finalresultobtained.Lackofknowledgeoftheinjuryisthe

main factor responsible for underdiagnosingTurco’s injury

anditscomplications.Thereisaneedforrandomized

prospec-tivestudiesthatcomparethetypesofsynthesismaterialand

the evolution ofthe casestreated withthese materials,in

ordertodefinethebesttreatment.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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