What is the diagnosis and management for a left foot X-ray showing osteoarthrosis and Lisfranc interval widening without fracture?

From the Guidelines

The diagnosis is a Lisfranc injury with osteoarthrosis of the left foot, and management should prioritize non-weight bearing, immobilization, and referral to an orthopedic foot specialist for potential surgical intervention. The left foot X-ray shows osteoarthrosis and Lisfranc interval widening without fracture, indicating a need for careful management to prevent further complications. According to the EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis 1, imaging is recommended in atypical presentations to help confirm the diagnosis of OA and/or make alternative or additional diagnoses.

Key findings from the X-ray include:

• Mild to moderate first and fifth metatarsophalangeal joint osteoarthrosis with tiny marginal osteophyte formation and subchondral/subcortical cystic change
• Osseous proliferation along the dorsal aspect of the Lisfranc articulations
• Periarticular degenerative changes elsewhere are mild
• Lisfranc interval widening, 0.6 cm, and malalignment of the second tarsometatarsal joint
• Soft tissue prominence throughout the forefoot
• Os peroneum

Given these findings, management should begin with immediate non-weight bearing using crutches or a walker, and immobilization with a short leg splint or cast. Referral to an orthopedic foot specialist is essential within 1-2 days as this injury often requires surgical intervention. Surgery typically involves open reduction and internal fixation (ORIF) with screws or plates to restore proper alignment of the tarsometatarsal joints. For pain management, prescribe NSAIDs such as ibuprofen 600mg every 6 hours or naproxen 500mg twice daily, along with acetaminophen 1000mg every 6 hours as needed. If pain is severe, short-term opioids like hydrocodone/acetaminophen 5/325mg every 6 hours for 3-5 days may be appropriate. Post-surgery rehabilitation includes 6-12 weeks of non-weight bearing followed by gradual weight bearing with physical therapy focusing on range of motion, strengthening, and gait training. This aggressive approach is necessary because Lisfranc injuries, which involve disruption of the tarsometatarsal joint complex, can lead to chronic pain, post-traumatic arthritis, and significant disability if not properly treated. The widening of the Lisfranc interval on X-ray indicates ligamentous disruption, which compromises midfoot stability even without visible fractures.

From the Research

Diagnosis

• The left foot X-ray shows no fracture, but there is anatomic alignment of the bones with mild to moderate first and fifth metatarsophalangeal joint osteoarthrosis, as described in 2.
• The X-ray also reveals tiny marginal osteophyte formation and subchondral/subcortical cystic change, which are characteristic of osteoarthrosis.
• Additionally, there is osseous proliferation along the dorsal aspect of the Lisfranc articulations and periarticular degenerative changes elsewhere, which are mild.

Management

• The management of osteoarthrosis includes rest, weight loss, physiotherapy, and the use of aids such as canes, shoe lifts, and elastic knee supports, as well as the judicious use of anti-inflammatory medications, as stated in 2.
• For Lisfranc injuries, treatment options include open reduction and internal fixation (ORIF) or primary arthrodesis, as discussed in 3, 4, and 5.
• A study in 5 found that primary arthrodesis had better short and medium-term outcomes than ORIF for primarily ligamentous Lisfranc joint injuries.
• However, another study in 4 suggested that ORIF with screws or partial arthrodesis is the treatment of choice in severe tarsometatarsal fracture dislocations, and primary complete arthrodesis should be reserved as a salvage procedure.

Lisfranc Interval Widening

• The X-ray shows Lisfranc interval widening of 0.6 cm and malalignment of the second tarsometatarsal joint, which are indicative of a Lisfranc injury.
• A study in 3 found that nonanatomic reduction, fracture classification of Myerson type C, and a history of smoking are risk factors for osteoarthritis (OA) after Lisfranc injuries.
• The same study in 3 also found that there was a substantial occurrence of posttraumatic OA, as evident on radiographs, albeit the occurrence of symptomatic OA was lower.

Osteoarthrosis

• Osteoarthrosis is a common disorder of synovial joints, seen most often in older patients, as described in 2.
• A study in 6 found that the first metatarsophalangeal joint is the most commonly examined joint in population-based epidemiological studies of radiographic foot osteoarthritis.
• The same study in 6 also found that estimates of the prevalence of radiographic first MTP joint OA in middle-aged to older adults ranged from 6.3 to 39%.