Lisfranc Fracture Dislocation Treatment & Management

Medical treatment is reserved for injuries that are anatomically stable and nondisplaced. This type of injury is best labeled as a sprain, although associated fractures in the surrounding bone may be present (eg, MT fracture). An athlete with a stable Lisfranc injury usually cannot compete for the remainder of the season. Early return to high-level activity can lead to chronic pain and progressive arthropathy. Therefore, athletes should be given special consideration.

Initial treatment should consist of a well-molded, non – weight-bearing, short leg cast worn for a minimum of 6 weeks. Advancement of ambulation depends on resolution of symptoms. Because many of these injuries initially present with midfoot edema that may help to stabilize damaged tissues, all stable injuries should be re-examined approximately 2 weeks following injury. Obtain weight-bearing radiographs at 4-6 weeks to ensure continued anatomic alignment.

After 6 weeks, progressive weight bearing can be allowed in a well-molded cast, advancing as comfort allows. When full weight bearing in a cast is comfortable, the patient can be advanced to a supportive shoe and reconditioning. The patient can be advanced to an accommodative orthotic with a contoured carbon shank so as to minimize midfoot stress.

Combined closed reduction and casting has no role in the treatment of unstable injuries. Constantly maintaining reduction with casting alone has proven to be too difficult. In addition, interposing soft tissues can impede closed reduction. For example, the anterior tibial tendon can block reduction of a lateral Lisfranc dislocation; similarly, the peroneus brevis tendon can block a medial dislocation reduction.

All injuries that are displaced and unstable require surgery.^[25] Complete assessment of the intercuneiform and cuboid integrity is important when determining stability. Clinical outcome is highly dependent on restoration of normal anatomic alignment. Present recommendations for treatment consist of open reduction of the unstable area, as well as rigid fixation, with an option in terms of the screws employed, such as 3.5-mm cortical screws or 4.0-4.5 cannulated screws (depending on the size of the bone).^[26] Multiple Kirschner wires (K-wires) also have been advocated, but maintaining reduction with them is more difficult (see image below).^[27] In fact, screw fixation has been shown to have significantly greater biomechanical stability than does K-wire fixation.^[28]

Guide wires should be placed carefully under fluoroscopic control to avoid multiple passes through the involved joint. In addition, they should be placed plantar to the midline to avoid fractures.

Other alternatives include the use of primary arthrodesis of the first, second, and third MT-cuneiform joints; suture button fixation; or dorsal bridge plating; however, the current evidence supporting the use of these techniques is modest at best.^[29]

Presentation variations

• Pure dislocation - Openly reduce all joints and follow with fixation of the medial joints with 3.5-mm cortical screws. Once anatomically aligned and fixed, the lateral 2 joints can be stabilized with 1.6-mm K-wires, if needed to maintain position. Wires are often not required, due to the ligamentous interconnections (see images below). CT scan in the coronal plane can demonstrate the extent of injury at the joint. Compare with the plain radiograph of this injury in the related image. Note the plantar avulsion, suggesting severe disruption of the plantar ligamentous structures. This diagram depicts the suggested fixation order of placement and alignment of screws for surgical fixation of unstable Lisfranc injuries. Preoperative anteroposterior radiograph demonstrates a Lisfranc dislocation. Preoperative lateral radiograph demonstrates a Lisfranc dislocation.
• Proximal instability - This includes tarsal instability and longitudinal impaction injuries that can disrupt the normal arcade of the TMT joints. Openly reduce and hold with fixation screws any instability between tarsal bones. If necessary, a mini-external fixator can be used to control proximal migration and comminution. Anatomically restore any shortening of the tarsals, and graft the defect with a structural graft from the iliac crest or proximal tibia. If more than 50% of the joint surface is destroyed, perform primary fusion among the involved bones to preserve long-term stability. Treatment then can proceed as it would for a pure dislocation (see images below). Postoperative anteroposterior radiograph demonstrates reduction and fixation of Lisfranc dislocation. Postoperative lateral radiograph illustrates placement of fixation screws for stabilization of Lisfranc joint.
• Distal fractures - MT fractures distal to the Lisfranc joint sometimes can interfere with stable fixation. In these instances, use intramedullary K-wires in conjunction with open reduction to anatomically realign the foot (see images below). Preoperative anteroposterior radiograph demonstrates a Lisfranc injury with proximal tarsal instability. The medial cuneiform is displaced medially, bringing the joint line level with the second. The proximal anatomy must be restored and stabilized before addressing the tarsometatarsal joint. Postoperative anteroposterior radiograph demonstrates restoration of normal midfoot alignment. Screw fixation was used to stabilize the cuneiform prior to realigning the Lisfranc joint. Due to comminution of the second and third metatarsal shafts, Kirschner wires were used to hold their position. In this case, due to continued instability, a wire through the fourth tarsometatarsal joint was also used.
• Interarticular injury - This involves destruction of the articular surface through either bony fracture or through traumatic removal of cartilage from the subchondral bone. Anatomically restore large fragments. Remove interarticular debris, and assess the remaining joint. If greater than 50% of the joint surface of the medial 3 joints is destroyed, consider acute fusion of these joints. Irrespective of the amount of damage to the articular surface of the lateral 2 joints, they should never undergo acute fusion.
• Patients with diabetes - If the dislocation is found acutely before onset of significant Charcot arthropathy, arthrodesis of the involved first, second, and third TMT joints can be beneficial. Take special care to document that blood flow is adequate for healing from the surgical procedure (transcutaneous pressure of oxygen [tcPO₂] or toe pressure >40 mm Hg). Fuse the medial 3 TMT joints, regardless of their articular integrity. Prolonged non–weight-bearing in a total contact cast is necessary to prevent reinjury due to neuropathy. Casting should be changed every 2 weeks. Weight-bearing status is assessed by evidence of solid fusion on follow-up radiographs. Fusions frequently take twice as long as nonneuropathic patients.

Often, surgery should be delayed until excessive swelling has resolved, because swelling places the soft tissues at risk. Supine position with a thigh or ankle tourniquet is recommended. Be aware of and ready to address all injuries present before beginning surgery.

A 2-incision approach works best for complete visualization. The medial incision is in line with the first webspace. The branches of the superficial peroneal nerve are identified and protected. The muscle belly of the extensor hallucis brevis covers the neurovascular bundle. Identify and protect the deep peroneal nerve, dorsalis pedis artery, and extensor tendons. Once the area of the second TMT joint is reached, perform subperiosteal dissection across the Lisfranc joint to minimize damage to soft-tissue structures. If needed, a second incision is based over the lateral border of the third MT and is carried distally. The extensor digitorum brevis is divided bluntly, and the TMTs are entered subperiosteally. In this region, the third, fourth, and fifth TMT joints literally are one on top of the other and are easily visualized.

With the tarsus stabilized and the joints inspected, reduction usually is easy. The author finds it easiest to reduce the medial column first, by placing a provisional wire across the first TMT joint and, if necessary, a provisional wire between the first and second cuneiform. If acceptable, appropriate cannulated screws are then placed. The second part of the procedure is connecting the medial and middle columns. A cannulated screw is placed across the medial cuneiform to the base of the second MT so as to reduce the Lisfranc diastasis. Other authors suggest starting with the second MT to medial cuneiform fixation. A large, pointed bone-reduction clamp can be used to hold the reduction while screws are placed. The position of the fixation screws is depicted in the image below.^[30]

Because no real tissue layers are present at this level of the foot, wound closure can be accomplished with an absorbable suture to close joint capsules and a nonabsorbable suture in using a vertical or horizontal mattress technique to close the skin.

Immediately postoperatively, the authors recommend a well-padded posterior splint until swelling subsides in 1-2 weeks. At that time, the splint can be converted to a non – weight-bearing, short leg cast if swelling permits. Immobilization in a cast is up to 3 months. The period of time that screws should remain is controversial, as is the question of whether weight bearing should be permitted before screws are removed. Physicians agree that screws across viable joints should be left in no longer than 6 months from the time of surgery. Some advocate that no weight bearing be allowed until the screws are removed, at 3 months after surgery.

• Remove sutures during the 2-week postoperative visit.
• Patient should remain immobilized in a non – weight-bearing, short-leg cast until 6-8 weeks after surgery. At that time, as symptoms permit, the cast can be switched to a removable boot or walking cast for another 6 weeks.
• During the 6-week postoperative visit, radiographically assess healing. If K-wires are used, they should be removed at the 6-week postsurgery follow-up visit.
• Follow up on a monthly basis until full weight bearing is achieved.
• Aftrer 4-6 months, remove fixation screws across the TMT joints. Allow weight bearing as tolerated in a supportive shoe with accommodative insole and carbon shank.

The following factors can be considered complications of this injury:

• Foot compartment syndrome after a major trauma
• Nonanatomic reduction or alignment
• Posttraumatic midfoot arthritis (most common)^[31]
• Painful hardware, hardware failure, or breakage
• Flatfoot deformity with instability with weight bearing
• Complex regional pain syndrome (only 2 cases reported)
• Neuromas (usually the superficial peroneal nerve)
• Infections and wound complications
• Vascular injuries^{[32, 33]}

Along this joint line, continued chronic pain with weight bearing is best treated with fusion of the first, second, and third TMT joints in an anatomically correct position. With realignment and stabilization of the medial joints, laterally based pain usually subsides.

Treat persistent lateral pain following realignment of the medial joints with interposition arthroplasty rather than fusion. This is best performed using a segment of extensor digitorum brevis tendon rolled up and interposed into the debrided joint. This allows continued motion and prevents the compressive bony contact that generates the pain (see images below).

Stable anatomic alignment is the best predictor of outcome.^[34] The presence of fractures and/or articular destruction leads to poorer results, regardless of alignment. Incidence of posttraumatic arthritis reportedly ranges from 0-58%.^[35] One study reported that up to 25% of patients develop posttraumatic arthritis even after fixation. This same study showed that there was no difference between acute and delayed (>6 weeks) surgical fixation. Purely ligamentous injuries seemed to have poorer outcomes. Good results are achieved with open reduction and internal fixation (ORIF) at up to 6 weeks, but poor outcomes are seen after this time due to articular destruction, malalignment, and poor soft-tissue envelope.

Role of acute fusion

Stability at this joint level of the foot is the primary concern, and instability appears to be the primary pain generator. Primary fusion of the medial 3 TMT joints has been advocated due to the unpredictability of adequate ligamentous healing to support the foot.

In 2006, Ly and colleagues reported the results of their study comparing primary arthrodesis with ORIF in primarily ligamentous Lisfranc injuries.^{[36, 37]} Twenty patients were treated with ORIF, and 21 were treated with arthrodesis of the medial 2 or 3 TMT joints, with an average follow-up period of 42.5 months. Using outcome measures, the authors reported that the members of the arthrodesis group reached a postoperative activity level that was an estimated 92% of their pre-injury activity level, while in the ORIF group, members achieved an activity level that was only 65% of their pre-injury level. The authors concluded that a stable, primary arthrodesis seemed to have better short- and medium-term outcomes. Whether this improves long-term results is not yet known.

Length of time before screw removal

Suggestions of length of time that screws should remain in place range from 6 weeks to 3 months after weight bearing begins (up to 6 months from the time of surgery). Results demonstrate that if fixation screws remain in place indefinitely, they have a high tendency to break with time, thereby causing pain. If the joint is not fused purposely during surgery, then some motion is expected; this constant motion causes hardware failure.

The timing of screw removal remains a question. Advocates of early removal stress the fear of early screw failure as the main reason for removal. Others believe that the screws should remain in place even during early weight bearing to slowly help condition the damaged ligaments to resume supporting the foot. Long-term follow-up is needed before this issue can be resolved.

Use of different bio-absorbable materials

The advantage of using different bio-absorbable materials to provide short-term stability following surgical reduction is that no screws need to be removed. Issues are 2-fold:

• What effect do degradation products have on joint chemistry?
• Is the sheer strength of bio-absorbable screws sufficient to maintain the reduction in this situation?

In 2002, Thordarson and colleagues reported results from 14 patients at an average follow-up of 20 months. At this short-term follow-up they determined that bio-absorbable screws are safe and that they eliminate the need for screw removal. Larger studies with long-term follow-up are needed to determine the true efficacy.^[38]